PREGNANCY AND LACTATION

PREGNANCY AND LACTATION PGND Ist SEMESTER APPLIED NUTRITION-I

NUTRITION DURING PREGNANCY AND LACTATION • Optimum nutrition is a great importance for women, due to their special nutritional needs associated with physiology changes such as menstruation, pregnancy, lactation and menopause. • Pregnancy and lactation are normal physiological processes, they increase considerably the nutritional requirement of the mother. Due to vomiting and loss of appetite generally reduced. • Further, additional nutrients are required for the growth of foetus. The baby weighing about 3.2kg at birth will contain about 500 g protein, 30 g calcium and 0.4 g of iron and varying quantities of different vitamins. • The increased nutritional requirements during lactation are due to the milk secreted by mother for feeding the baby.

Physiologic changes of pregnancy • Blood volume and composition- many physical and biological changes occur in normal pregnancy. Blood volume expands by 50% resulting in decrease in hemoglobin levels, blood glucose values, and serum level of albumin, other serum proteins and water-soluble vitamins. • Gastrointestinal changes- The functions of gastrointestinal system changes in several ways that affect nutritional status. Nausea, vomiting and constipation occur. It has been observed that the pregnant women often show craving for some foods and aversion to others.

Renal function- due to foetal and maternal metabolism during pregnancy, there is an increased production of various metabolites like creatinine, urea and other waste products. To facilitate their clearance, the rate of blood flow through the kidneys is increased with a subsequent increase in the rate of glomerular filtration in the nephrons • Increased basal metabolic rate- due to foetal growth and development there is an increase in basal metabolic rate which rises by about 5% in the 1st trimester reaching to as high a level as 12% during later stages of pregnancy, when the rate of foetal growth is very high.

Rate of growth during pregnancy New life is created from the moment the ovum gets fertilized. The fertilized ovum or embryo grows and the process of making an individual starts. The embryo which is about 2” long and weighs about 15 g around 12th week grows to a full grown baby weighing about 3kgs by full term.

Table: Fatal weight and maternal weight gains at different ages in gestation

Nutritional requirements during pregnancy • Energy- during pregnancy additional energy is required to support the growth of the foetus, development of placenta and maternal tissues and to meet the needs for increased BMR. The total calories cost of supplying and maintaining the foetus has been estimated to be about 40,000 Kcal. Since the greater part of calories will be required mostly during the 2nd and 3rd trimesters, the additional requirements will work out to 200 Kcal per day.

Protein-Available evidence would indicate about 910 g of protein is deposited in the foetus and maternal tissues during pregnancy. The average daily increment is estimated to be about 5 g during the last six months of pregnancy. The I.C.M.R. nutrition expert group recommended an extra allowance of 10 g per day.

Iron-it has been estimated that about 540 mg iron is found in the foetus and maternal tissues. This will work out to about 2-3 mg iron per day during the last six months of pregnancy. Since, the iron from diets is utilized only to an extent of about 20% in pregnant women, the extra dietary iron requirements will be about 10-15 mg per day.

Calcium-it has been estimated that about 30 g calcium is deposited in the foetus during pregnancy. This will work out to about 150 mg of extra calcium during the last 6 months of pregnancy. Since dietary calcium is utilized to the extent of about 25% in pregnancy, the additional requirements will work out to 600 mg in terms of dietary calcium. • Vitamin A-the quantity of vitamin a is found in the liver of infant about 5400 – 7200 µg of retinol and this will work out to about 25-35µg additional retinol per day. Since the requirement are small as compared with the daily requirements of 750 µg for a normal woman.

Thiamine, riboflavin and nicotinic acid-small quantities of these vitamins are present in the tissues of new born infants. The extra calorie allowance of 300 Kcal per day for pregnant woman will need an increase in the requirements of these vitamins. The I.C.M.R. nutrition expert group has recommended can additional allowance of 0.2 mg thiamine, 0.2 mg riboflavin and 2.0 mg nicotinic acid per day. • Folic acid and vitamin - small amounts of folic acid and vitamin are present in the tissues of new born infants. The I.C.M.R. nutrition expert group has recommended an additional daily allowance of 50-200 µg of free acid and 0.5 µg of vitamin.

Ascorbic acid- small amounts of ascorbic acid are present in the tissues of new born infants. The I.C.M.R. nutrition expert group was of the opinion that the daily allowance of 50 mg for a normal woman would meet the additional requirement during pregnancy.

Table: Balanced Diet for a pregnant woman (Sedentary work) For Non-vegetarians 30 g of pulses can be substituted with 50 g of meat / chicken / fish / egg

Diet during pregnancy: • The basic principle of meal planning remains the same, but since the nutritional requirements increase during pregnancy, emphasis should be in including nutrient dense foods i.e., foods that give more nutrients per calorie consumed. • During early months, the mother often suffers from morning sickness due to the hormonal and physiological changes, when she should be given small amounts of foods with increased frequency. Solid carbohydrate rich foods like bread, biscuit and fruit given in the morning or before meals helps to relieve nausea. Also fried, rich, strongly flavored and spicy foods need to be avoided.

To meet increased requirements the mother should consume extra food. Her feeding pattern should be 5-6 meals a day. Protein needs can be met by including good quality protein foods like meat, milk, egg, fish. Protein can also be obtained from pulses like soya bean and groundnut at a lower cost. • To meet additional iron needs foodstuffs like whole grain cereals, rice flakes, puffed rice, dried fruits, green leafy vegetables, eggs, enriched cereals and organ meats can be given. • Food rich in dietary fibre like fresh fruits, vegetables, whole grain cereals with plenty of fluids need to be included. This is to ward off constipation which is a common problem during pregnancy

Problem during Pregnancy • Nausea and vomiting- Generally it is mild and occurs during early pregnancy and is commonly called “morning sickness” as it tends to occur early in the day, but can occur at any time. At least 50% of all pregnant women, most of them in their first pregnancy, experience this condition. • Constipation- is common during the later half of pregnancy. Hormonal changes in pregnancy tend to increase relaxation of gastrointestinal muscles. Pressure of developing foetus on the digestive tract may make elimination difficult at times.

Hear burn or gastric pressure- Some pregnant women may complain of “feeling of fullness” or “heart burn” during later half of pregnancy. This is usually due to the pressure of the enlarging uterus crowding the stomach. • Anaemia- A pregnant woman is labelled anaemic if the blood hemoglobin is less than 10g/100ml from the 28th week onwards. A significant fall in birth weight due to increase in prematurity rate and intrauterine growth retardation can occur if the haemoglobin level goes below 8 g / 100 ml.

Other consideration: • Alcohol- the habitual use of alcohol during pregnancy can cause foetal damage. Extensive or habitual alcohol use may produce offspring with foetal alcohol syndrome (FAS). Infants with FAS are premature and have low birth weight. • Caffeine can cross the placenta and enter foetal circulation. Pregnant women who are heavy coffee drinkers are considered at risk for miscarriages, premature deliveries and may give birth to small for date infants.

Drugs- drug use pregnancy-medical or recreational- also leads to numerous problems. Recreational drugs like heroin, LSD, marijuana lead to poor prenatal weight, short or prolonged labour and other prenatal problems. • Smoking during pregnancy results in placental abnormalities and foetal damage including prematurity and low birth weight. This is mainly due to reduced blood flow, which affects the oxygen and nutrient transport through the placenta.

Recommended dietary allowance of various nutrients during pregnancy (ICMR,1990)

LACTATION Milk output varies in the lactating mother. The WHO expert committee assumed the average output to be 850 ml per day while the I.C.M.R. nutrition expert group assumed an output of 600 ml per day.

Composition of breast milk Soon after delivery small quantities of thick, yellowish, viscous liquid called colostrum is secreted which is rich in antibodies and Vitamin A. This should be given to the baby and not discarded. After a few days of lactation the mother secretes larger amounts of less viscous and whitish milk known as “mature milk” which is more or less a complete food nutritionally. A healthy mother secretes 850ml of milk daily for which her nutritional needs are increased enormously

Table : Composition of mother’s milk

Nutritional requirements during lactation • Calories-it has been estimated that the efficiency of conversion of diet calories to human milk calories is only 60%. On the basis, production of 420 milk calories will need 700 diet calories. The I.C.M.R. nutrition expert group recommended an additional 700 Kcal during lactation. • Protein-the average NPU of the diets consumed in India is about 50. For the production of 7.2 g of milk proteins, about 14.4 g of dietary proteins will be required. The I.C.M.R. nutrition expert group recommended an extra allowance of 20 g of protein per day.

Calcium- the quantity of calcium present in 600 ml of human milk is 205 mg. since the retention of dietary calcium in lactating women is about 30 per cent, the additional dietary calcium requirement will be about 700mg per day. The I.C.M.R. nutrition expert group recommended an extra allowance 500-600 mg daily. • Iron- the iron content of 600 ml of human milk is about 0.72mg. Since only about 20 percent of the dietary iron is retained in lactating women, it will be essential to provide about 3.6 mg of extra iron in the diet. The I.C.M.R. nutrition expert group recommended an extra allowance for iron for the lactating women.

Vitamin A-the quantity of vitamin A present in 600 ml of human milk is 300 µg. The I.C.M.R. nutrition expert group recommended an additional allowance of 400of vitamin A. • Thiamine, riboflavin and nicotinic acid- Additional calorie requirements during lactation are 700 Kcal. The extra requirements of thiamine, riboflavin and nicotinic acid to meet the needs of extra calories will be 0.3 mg, 0.4 mg, and 4.6mg/day respectively.

Ascorbic acid-the quantity of ascorbic acid present in 600 ml of human milk varies from 15-30 mg. The I.C.M.R. nutrition expert group recommended an additional allowance of 30 mg of ascorbic acid. • Folic acid and vitamin-the quantities of folic acid and vitamin present in 600 ml of human milk will be 6and 0.14µg respectively. The I.C.M.R. nutrition expert group recommended an additional allowance of 50µg of folic acid and 0.5µg of vitamin.

Diet during lactation: A lactating mother requires not only large quantities of body building and protective foods but also additional energy yielding foods to facilitate copious formation and secretion of breast milk. Besides adhering to the basic principles of meal planning the following guidelines need to be considered. • Large amount of fluids are essential for milk production. Therefore adequate fluids such as milk, fruit juice, milk based beverages and even water must be encouraged.

The choice of food is wide during lactation. No food need to be restricted except spicy and strong flavored foods which might impart flavour to milk that may be repulsive to the baby and that may cause gastric distress to the mother. • Almost all medicines taken during lactation are absorbed into mother’s blood and are secreted in the milk. Hence any medicine during lactation must be avoided or taken under strict medical supervision. • Since the nutrient needs are enhanced, the meal pattern may be changed to 5-7 meals a day by introducing in between snack between the meals

Table: A balanced vegetarian diet for a nursing mother doing sedentary work For Non-vegetarian substitute 30 g of pulse with 50 g of meat / fish / chicken / egg.

Recommended dietary allowances of various nutrients during lactation(0-12 months)

PREGNANCY AND LACTATION