LACTATING AND PREGNANT WOMAN

NUTRITION FOR PREGNANT AND LACTATING WOMANPresented by:Deepak Kumar MandalMadan PandeyB. Sc. Nutrition & Dietetics

Tribhuvan UniversityCentral Campus of TechnologyDharan, Sunsari, Nepal

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Pregnant woman 2

ContentsIntroductionPhysiological changesFactors Affecting Pregnancy ComplicationsNutritional RequirementBalance dietConclusion

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Introduction

Pregnancy is a normal physiological phase where rapid growth of fetus takes place in the mothers uterus along changes with in her body. The physiological and hormonal changes help to better accommodate the fetus.The blood sugar level, breathing & cardiac output are also increased.

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ContLevel of progesterone & estrogen rise continuously.

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Physiological changesEnergy metabolismBasal metabolism increases due to development of fetus and other physiological changes.The increase in BMR relative to pre-pregnancy values are about 5.3%, 11.4% and 25.3% during the first, second and the third trimester respectively.6

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ContGrowth of maternal tissuesMaternal tissues including breasts, uterus and adipose tissues increase in size.Hormones promote growth and changes in breast tissues.7

ContAlimentary FunctionsReduced gastric tone, motility and secretion.Nausea and constipation are common.Efficiency of absorption of calcium, iron, vitamin B12 and other nutrients increases.8

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ContRenal FunctionGlomerular filtration rate increases to clear substances such as creatinine, urea, uric acid etc.Rate of excretion of water is higher in mid-pregnancy, very low in advanced stage.Mild glycosuria is common.Increased loss of free amino acids and iodine in urine.Decreased excretion of calcium & B-vitamins.9

ContBlood CompositionIncrease in plasma volume about 50% and RBC mass by 20%.Increase in total haemoglobin but decrease in its concentration.Fall in total serum protein.Decrease in concentration of vitamin A, ascorbic acid and increase in concentration of carotene, tocopherols, cholesterol and N-methyl nicotinamide. 10

ContWater Balance and Weight GainAverage weight gain is about 12 Kg but it may range from 6 Kg to 18 Kg.Total body water increases by average 7 Kg.Kidney may have some difficulty in disposing surplus water.

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complicationsNausea & vomitingDue to nervous disturbance, placental protein intoxication or derangement of carbohydrate metabolism.Feeling of nausea may be higher if food is eaten at too much hunger.Frequent and small meal should provided.Fat rich, fried, spicy foods should be restricted.12

ContLeg crampsDue to sudden contraction of muscles.Related with decline in serum calcium level.FatigueCaused by progesterone disturbances.13

ContHeart burnDue to increased progesterone levels which decreases smooth muscle mobility of stomach and pressure by growing uterus on stomach.Can be relieved by providing small & frequent meals and drinking fluids between meals.14

ContPre-eclampsia & eclampsiaDisorder ofpregnancycharacterized by hypertension and proteinuria.Symptoms may be swelling, convulsion (shaking of body), nausea, vomiting, headache, temporary loss of vision, or coma.Adequate amount of proteins, vitamins & minerals should be provided.

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ContConstipationDue to pressure of enlarged uterus & effect of placental hormones on GI tract.Increment of fluid intake & fibre in diet, regular sleeping & exercise habit helps in elimination.

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ContAnaemiaAccording to WHO, a pregnant woman is anaemic if hemoglobin level is 11mg/dl or haematocrit percent is below 33%.The concentration of haemoglobin in blood is lowered due to increased plasma volume.May be due to iron deficiency, folate deficiency (megaloblastic), less often due to vitamin B12 deficiency.17

ContSupplements of iron and folic acid should provided.Regular consumption green leafy vegetables, whole cereal grains & pulses, animal meat & liver and vitamin C rich foods is to be increased.18

ContGestational Diabetes MellitusRefers to carbohydrate intolerance during pregnancy.Caused due to impaired insulin action.Insulin antagonism is probably due to combined effect of placental hormones.Resolves after delivery.19

Factors Affecting PregnancyDiet Diet is a main factor that influences in health of mother.Consumption of ill-balanced and inadequate diets leads to deterioration of physical and mental strength, development of anaemia and general weakness. 20

Cont......Socio-economic Factor Still birth and neonatal death rates are generally high among the pregnant women belonging to low socio-economic status.The low standard of living, living in insanitary surrounding and poor quality diets are reasons for high still birth and neonatal death.

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ContMother body size Generally tall women have babies with greater body length and weight than those born to short women. It has been found that: Babies born to short women are 8% lighter than those born to tall women. Babies born to under weight women are 8% lighter than those born to over weight women.Babies born to tall and heavy women are about 14% heaver than those born to short and light women.22

Nutritional RequirementsCaloriesApproximately 77,000 Kcal energy is required per pregnancy if weight gain is supposed to be 12Kg.More than 40,000 Kcal is accounted by protein & fat storage.For this, ICMR (2010) has recommended additional calorie intake as below:

23TrimesterAdditional Requirement First85Kcal/daySecond280Kcal/dayThird470Kcal/day

ContFurther allowance has to be made for spontaneous decrease in physical activity particularly occurs in third trimester.

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Cont CarbohydrateIt is main source of extra calories during pregnancy. A fiber rich diet is recommended to help prevention of constipation and hemorrhoids.

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Cont Fat Dietary fats provide vital fuel for the mother and development of fetus. Need of essential fatty acid is slightly higher than those of non-pregnant women during pregnancy. Very low fat diets (which provide less than 10% daily calories from fat) do not supply sufficient essential fatty acid, fat-soluble vitamins or calories. Diet should contain at least 30 gm visible fat(ICMR, 2010)

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Cont ProteinAbout 597 g of protein is deposited during pregnancy in fetus and maternal tissues. To fulfill this requirement, ICMR(2010) has recommended an extra allowance of dietary protein as below:

27TrimesterAdditional requirement(gm/day)First0.6Second8.1Third27

Cont Calcium About 30g of calcium is deposited in fetus during pregnancy.Maternal reserves are in positive balance.Absorption is not less than 40% of calcium available in diet during pregnancy. ICMR(2010) has recommended an extra 600mg (total-1200mg) calcium per day. 28

ContIron Fetus and placenta contain about 230mg and 100mg of iron respectively.Increment of RBC mass increases about 296mg of iron.Since menstruation stops iron losses is minimized to 234mg for period of pregnancy. The additional 860mg of iron is required when above factors are considered.29

Cont This requirement is fulfilled by providing additional 14mg (total 35mg) iron per day in diet (recommended by ICMR,2010). Here, it is supposed only 8% of iron is absorbed from diet.30

ContVitamin AThe liver of infant at birth contain about 5,400 g to 7,200 g of retinol.To fulfill this requirement ICMR (2010) has recommended following additional dietary allowances:200g (800 g total) as retinol1600 g (6400g total) as -carotene

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ContThiamineSmall amounts of thiamine are stored in tissue of new born infant.Extra calorie allowance requires extra thiamine.Thus, ICMR(2010) has recommended an extra allowance of 0.2 mg per day of thiamine.

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ContRiboflavinSmall amounts of riboflavin are found in tissues of new born infant.Extra calorie allowance requires extra riboflavin.Thus, ICMR(2010) has recommended an extra 0.3mg per day of riboflavin.

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ContNiacinNicotinic acid and coenzymes I & II containing nicotinamide are found in tissues of new born infants.Extra calorie allowance requires extra niacin. To fulfill this requirement, ICMR(2010) has recommended extra allowance of 2mg per day.34

ContFolic acidThere is rapid growth of fetus.Total number of RBCs also increases.Folic acid is required for synthesis of DNAs & RNAs.ICMR(2010) has recommended an extra allowance of 300 g (total 500 g) of folic acid per day.

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ContVitamin B6: ICMR(2010) has recommended additional 0.5 mg (total 2.5 mg) of vitamin B6 per day. Vitamin B12: Extra 0.2 g (total 1.2 g) of this vitamin has been recommended.Ascorbic acid: 20mg extra requirement (total 60 mg) during pregnancy.

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ItemsQuantityCereals475gmsPulses55gmsLeafy vegetables100gmsOther vegetables40gmsRoots and tubers50gmsMilk and milk products250mlOils and fats40gmsFruits 60gms Sugar and Jaggery40gms

Composition of Balanced Diet during PregnancySource: ICMR- 198437

ConclusionPregnancy is stage of rapid growth of infant in mothers body.Her body itself changes physiologically to help growth of fetus & for preparation of lactation.Thus, sufficient nutrients from diet, proper health care & sanitary conditions should maintained for safe delivery.38

LACTATING WOMAN 39

contentsIntroductionHormonal control of lactationLactation and growth of infantNutritional requirementsBenefits of breast feedingPractices to avoid during lactation40

IntroductionLactation is a normal physiological process in which there is production of milk by mammary glands of mother after delivery of her child.Milk is only source of energy and nutrients for the newly born baby.It promotes optimal physical and mental growth of infant.41

Hormonal control of lactation

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Lactation and growth of infantMilk yield is 500ml in first month, & reaches up to 1litre in fifth month and declines steadily later.Average milk production is about 650ml.Doubling of weight in first six months indicates infant is getting sufficient nutrient.

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ContGrowth can be monitored by using growth chart.Along with age of infant, other factors such as age, health and nutrition of mother influences the volume of milk produced.

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ContThe composition and output of milk are likely to be affected by mothers diet and state of nutrition.Studies have shown that:High fat diets slightly increase the fat content of milk and its output.High protein diet slightly increase milk output.45

Nutritional requirementsLactating womans nutritional supplies should:Meet her own body needs.Provide enough nutrients in milk.Furnish energy for mechanism of milk production.

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Cont CalorieNursing mother needs more than 1000kcal extra energy for metabolic work to produce milk and calorie content in milk.It is partly fulfilled by mobilization of fat stores in body and partly by dietary supply.

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ContThus, ICMR(2010) has recommended additional:600Kcal energy for first 6 months520Kcal energy for next 6 months48

ContProteinProtein requirement of lactating mother is calculated on the basis of milk output and protein concentration in it.ICMR(2010) has recommended following allowance of protein:49Lactation periodAdditional Requirement0-6 months22.9g6-12 months15.2g

ContFatQuantity of fat in mothers diet does not influence the fat content of milkComposition of milk fat reflects composition of fat in mothers diet.Sufficient amount of fat should be consumed in order to get sufficient unsaturated fatty acids & fat soluble vitamins.Diet should contain at least 30 gm visible fat.50

ContCalciumBreast feeding is associated with transfer of approximately 200mg calcium per day.Supposing the retention of dietary calcium about 30% in pregnant mother, ICMR(2010) has recommended additional 600mg (total-1200mg) calcium per day.

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ContIronMothers milk is not a good source of iron.It contains about 0.78 mg/l iron, so loss iron from milk is about 0.5mg a day.Loss of iron from body is 0.77mg/day.To compensate these loss, ICMR(2010) has recommended total 25mg iron per day.52

ContVitamin AThe quantity of retinol in milk is about 50g/dl; total about 350g.Thus, ICMR(2010) has recommended additional vitamin A requirement as below:

53Additional Requirement Retinol350g (total 950g)-carotene 2800g (total 7600g)

ContB-vitaminsBreast milk contains all types of B-vitamins.Increased energy need also increases need of these vitamins.Content of these vitamins in milk depends upon content in mothers diet.

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ContThiamineAbout 0.2mg thiamine per day is secreted via milk.Additional recommendations are:For 0-6 months of lactation: +0.3mgFor 6-12 months of lactation: +0.2mg

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ContRiboflavinAbout 0.3mg riboflavin is secreted in milk per day.ICMR(2010) has recommended:Additional 0.4mg for first six monthsAdditional 0.3mg for next six months

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ContNiacinNicotinic acid secreted in milk per day is about 0.9 to 1.2mg.Allowance of niacin is:Additional 4mg for first six months Additional 3mg for next six months

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ContVitamin B6: Additional 0.5 mg pyridoxine has been recommended.Vitamin B12 : Additional 0.5g is recommended.Ascorbic acid: About 3mg/dl ascorbic acid is secreted in milk.Additional 40mg has been recommended,(with consideration of cooking loss)58

Benefits of breast feedingBenefits to infantProtects from infections & illness including diarrhea, pneumonia, asthma.Decreases risk of obesity.Reduced risk of diabetes & cardiovascular diseases.Decreases health care costs.

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ContBenefits to motherStimulates uterine contraction.Convenient because no requirement of preparing, mixing & heating.Less expensive than formula feeding.Reduces risk of breast cancer, ovarian cancer, osteoporosis.60

Practices to Avoid If mother drinks alcohol or use drugs they are seen in milk.So illicit drugs, alcohol, smoking should avoided.61

conclusionMilk is exclusive source of nutrients and energy for infant.Proper nutritional care is required for both infant and mother.Breast feeding benefits both mother and infant.

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REFRENCESEssentials of Food and Nutrition(volume 1);Dr. M swaminthanDietetics; B. Srilakshami; New age InternationalDiscovering Nutrition; Paul Insel, Don Ross, Kimberley McMahon, Melissa Bernstein; Jones & Bartlett Learning NUTRIENT REQUIREMENTS AND RECOMMENDED DIETARY ALLOWANCES FOR INDIANS, 2009 ;Indian Council of Medical Research; Jamai-Osmania PO, Hyderabad 500 604

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