Chapter 11

1. Chapter 11 Maternal and Infant Nutrition in Health and Disease

2. Learning Objectives • Identify nutritional needs during pregnancy, lactation, and infancy. • Discuss the benefits of lactation and management techniques. • Discuss infant feeding strategies.

3. Nutrition for a Healthy Pregnancy Begins Before Conception Weight loss can increase fertility especially in those with PCOS Achieve normal BG levels before conception (with diabetes) Avoid excess vitamin A (preformed) to reduce risk of birth defects Vegans require vitamins B12, D, and calcium B12 deficiency associated w/ impaired neurologic development Deficiency issues on fetal growth and development Pyridoxine (vitamin B6) deficiency may lead to impaired learning and memory retention as well as Down syndrome Folic acid deficiency increases risk for Neural tube defects (spina bifida), Down syndrome and Cleft palate Rule out celiac disease if Hx of following: Infertility or Miscarriages Low-birth-weight infants Family Hx neural tube defects

4. Comparison of Weight Gain Goals Past Goals: 1960s < 20 lb More recently: 25-35 lb (BMI 20-26) 28-40 lb (BMI <20) 15-20 lb (BMI >26) Current Goals: From Institute of Medicine (IOM): Up to 30 lb normal weight Up to 25 lb overweight 15 lb for obesity For multiple births (triplets): 35 to 45 lb normal BMI Goal to prevent low birth weight and macrosomia

5. Components of Weight Gain Components of weight gain during pregnancy. (From Murray SS, McKinney ES, Gorrie TM: Foundations of maternal-newborn nursing, ed 4, St Louis, 2006, Saunders.)

6. Prenatal Weight Gain Chart • How many extra calories per day do you need? Recommended prenatal weight gain. Chart to monitor weight gain throughout pregnancy. PGW, Pregestational weight (weight before conception). (From the New York State Health Department, WIC Program.)

7. Risk Factors for and Related to Macrosomia Birth weight >4 kg (8.8 lb) Women who gain >IOM weight gain recommendation are three times more likely to have infant with macrosomia(Hedderson et al., 2006) Uncontrolled diabetes—in first trimester due to alterations in placental growth and function(Jansson et al., 2006); later trimesters related to high glucose levels through placenta Macrosomia increases risk of shoulder dystocia (head normal size, shoulders too large for normal delivery) and risk of birth canal injuries(Hirnle et al., 2007) Neonatal hypoglycemia (BG <40 mg/dL) and hyperbilirubinemia Increased risk for infant’s later development of metabolic syndrome(Boney et al., 2005)

8. Risks of Low Birth Weight (LBW) Low birth weight: <5.5 lb of unknown etiology Small-for-gestational age (SGA) <10th percentile height or weight based on gestational age; may also be referred to as intrauterine growth retardation (IUGR) SGA infants are at later risk of hypercholesterolemia IUGR or LBW related to low-normal kidney function in adulthood Increased risk of occurrence with poor dietary intake and inadequate weight gain during pregnancy

9. Biochemical & Nutrient Issues Increased need for protein: 75-100 g Nutrients that are often low in a pregnant woman's diet and may require supplementation are: Omega-3 fats to promote good neurologic development of fetus and infant Calcium: Many women may not get enough calcium before conceiving and are already at risk for bone loss. 1,300 mg/day for women 18 years of age and younger 1,000 mg/day for women >19 years Vitamin D: 800IU/day Iron: good sources include fortified breakfast cereals & prenatal vitamin. 27 mg/day Folate: <18 years, 800 mcg >18 years, 1,000 mcg/day (IOM 2004) Fiber: 25-35g/day to help prevent constipation due to slower transit time

10. Other Nutrition Issues in Pregnancy Hydration: dehydration is the number one cause of early labor Safe food handling to prevent food poisoning Steam or heat deli meat to lower risk ofListeria Avoidance of excess mercury intake Decreased intake of tuna, shark, swordfish, marlin, and lake trout Small fish generally low in mercury (e.g., sardines) Wild salmon good source of omega 3’s and low in mercury

11. Prolonged Hyperemesis Can cause dehydration; hospitalization needed for IV fluid replacement Associated with vitamin deficiencies: Beriberi and Wernicke’s encephalopathy Possible fatal electrolyte imbalance May cause hemorrhage due to rupture of esophageal varices Parenteral nutrition may be required via venous access Monitor for ketones May benefit with Small, frequent meals, including snacking on crackers Vitamin B6(Powers et al., 2007) Ginger(Ensiyeh and Sakineh, 2008)

12. Diagnostic Screening for Diabetes 100-G Glucose Load75-G Glucose Load Fasting 95 (5.3) Fasting 95 (5.3) 1-hr 180 (10.0) 1-hr 180 (10.0) 2-hr 155 (8.6) 2-hr 155 (8.6) 3-hr 140 (7.8)

13. Third Trimester Issues Mother may experience heartburn; small frequent meals and sitting up after eating can help Constipation can be a problem because of diminishedperistalsis for increased intestinal absorption of nutrients; include fiber, water, and exercise as tolerated Restless leg syndrome: transient form found in up to 1 in 4 women during pregnancy; associated with low hemoglobin Pregnancy-induced HTN (PIH) or gestational HTN-preeclampsia: a leading cause of maternal and fetal morbidity and mortality Eclampsiacan lead to convulsions and coma. Treated with magnesium sulfate

14. Other Concerns Avoid alcohol to prevent fetal alcohol syndrome, mental retardation and deformities such as wide set eyes Avoid caffeine, a vasoconstrictor to ensure good oxygen uptake by fetus Physiologic Anemia—may be caused by increased blood volume, but in the United States is still treated with iron supplements Pica– eating non nutritive items such as dirt or paint chips and may be associated with iron deficiency

15. Lactation Goals The American Academy of Pediatrics recommends exclusive breastfeeding/nursing for 6 months and continued nursing through the first year of life or longer, as desired

16. Benefits of Lactation Colostrum and milk provide antibodies and immunity factors to the breastfed infant Hormones promote uterine contractions that aid return toprepregnancy size and promote weight loss by mother Babies’ “chewing” action promotes strong jaw muscles and helps prevent baby-bottle mouth (tooth decay) Baby becomes a “gourmet” eater with increased acceptance of variety of foods later in life DHA (omega-3 fat) promotes brain development and increased visual acuity Reduced risk for later obesity of the child

17. Ten Steps to Promote Lactation Maintain a written breastfeeding policy that is routinely communicated to all health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within one hour of birth. Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants.

18. Give infants no food or drink other than breast milk, unless medically indicated. Practice “rooming in”—allow mothers and infants to remain together 24 hours a day. Encourage unrestricted breastfeeding. Give no pacifiers or artificial nipples to breastfeeding infants Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic(BFUSA, 2004). Ten Steps to Promote Lactation (continued)

19. Support Woman’s Confidence Eight to 12 feedings per 24-hour period a sign of good intake (may be spread evenly over this time or increased frequency in days and less at night) Six or more wet diapers per 24-hour period indicate good milk production (assuming no water bottles) Remind women during periods of growth spurts that “supply and demand” will result in increased milk production Refer any woman having or perceiving lactation difficulty to La Leche League (local chapter representative can be found on-line) or to an International Board-Certified Lactation Consultant (IBCLC) at a local hospital

20. Nutritional Concerns with Lactation Mother’s diet must be adequate B vitamins Vitamins A and D Minerals: calcium, iodine, selenium Nursing infant further advised to take vitamin D supplement especially in high-risk populations (lack of sunshine, darker skin color) Vegans and women with hx bariatric weight loss surgery need supplement of vitamin B12 No excess weight loss to ensure adequate kilocalories for milk production needs (½ lb/week appropriate; initial rapid weight loss result of fluid loss after delivery)

21. Breastfeeding versus Bottle-Feeding Issues Frequency Breastfeeding required every 2 to 3 hours or 8 to 12 times per24 hours for the young infant (older infants can go longer periods with lower frequency) Formula is more difficult to digest; baby may go longer stretches between feeds but not receive adequate nutritional intake for optimal growth and development Breastfeed—no preparation, “ready to go”; bottle requiressterilization and heating Vitamin D may be needed by infant with either method Breast milk can be pumped or hand-expressed by working moms; breast milk or soy milk formula can be given in a bottle after breast-feeding well established (>1 month of age)

22. Bottle-Feeding Concerns Iron-fortified formula advised Formulas now available with added omega-3 fats Powdered form needs careful measuring, mixing Liquid (concentrated) diluted 1:1 with water Need safe water source and sterile bottles Refrigeration required after mixing or opened liquid concentrate

23. Introduction to Solids No solids until ages 4 to 6 months when GI tract is ready and the baby has the ability to indicate satiety Start with low allergenic foods—baby rice cereal with ironto maintain iron status Add new foods one at a time to rule out allergies; vegetables before fruits may allow better acceptance of veggies Add pureed meats after age 6 months Pincer grasp by approximately age 9 months; add water by cup; solids in small pieces to prevent choking

24. Critical Thinking • What can a nurse do to support breastfeeding in the hospital setting? • What are the immediate and long-term concerns about breastfeeding and their possible resolutions?

25. Study Guide • Vocabulary • Macrosomia • Hyperbilirubinemia/ Jaundice • Neural tube defects • Hyperemesis gravidarum • Physiologic anemia • Pica • Lactation • Colostrum • What vitamin may cause birth defects if in excess? • What B vitamin is needed to prevent neural tube defects? • What two B vitamins may play a role in preventing Down Syndrome?

26. Study Guide (continued) • What can help increase fertility in a woman with PCOS? • Current weight gain goals for pregnancy • How many extra calories per day does a pregnant woman need? • What problems are associated with macrosomia? • What problems are associated with low birth weight? • Why are women’s blood sugars screened during pregnancy? • What nutrients may need to be supplemented in pregnancy? (see slide 10) • What is the number one cause of early labor?

27. Study Guide (continued) • Why are pregnant women concerned about listeria and mercury and what foods are they found in? • Why avoid alcohol and caffeine? • How long are women encouraged to breast feed? • Lactation benefits • Approximately how many kcal are used to produce milk? • What is an appropriate rate of weight loss after birth? Why not more? • Compare breastfeeding and bottle feeding issues • What age is appropriate to start solid food? • Why give infant rice cereal?