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Chapter 11 Nutrition During Pregnancy and Infancy Changes in the Body During Pregnancy • Fertilization: the union of a sperm and an egg. • Implantation: the process through which a developing embryo embeds itself in the uterine lining. • Embryo: the developing human from two through eight weeks after fertilization. • Prenatal development: o Ovulation releases an egg from the woman’s ovary. o Fertilization occurs in the oviduct 12 to 24 hours later. o About 30 hours after fertilization, the fertilized egg has completed its first cell division. o About 3 or 4 days after fertilization, the developing embryo is a ball of about 100 cells. o About 6 days after fertilization, the developing embryo begins to implant itself in the uterine lining. ▪ Implantation is complete by 14 days after fertilization. o During the embry onic stage of development (2 to 8 weeks) , cells differentiate and arrange themselves in the proper locations to form the major organ systems. o The fetal stage of development (9 weeks until birth) the fetus gro ws, and internal and external structures continue to develop . Nourishing the Embryo and Fetus • Placenta: an organ produced from maternal and embryonic tissues. o Secretes hormones, transfers nutrients and oxygen from the mother’s blood to the fetus, and removes metabolic wastes. • Fetus: a developing human from the ninth week after fertilization to birth. • Fetal period usually ends after 40 weeks with the birth of an infant. o Birth weight: 3 to 4 kg (6.5 to 9 pounds). • Small for gestational age: infants born o n time but have failed to grow well in the uterus. • Pre -term or premature: infant born before 37 weeks of gestation. • Low birth weight: a birth wei ght of less than 2.5 kg (5.5 lb). • Very low birth weight: a birth we ight of less than 1.5 kg (3.3 lb ). Maternal Weight Gain During Pregnancy • Healthy, normal weight woman should gain 11 to 16 kg (25 to 35 lb) during pregnancy. o Little gain is expected during the first trimester: 1 to 2 kg (2 to 4 lb). o Second and third trimester: 0.5 kg (1 lb)/week. • Underweigh t women should gain up to 18 kg (40 lb ). • Overweight women should gain onl y about 7 to 11 kg (15 to 25 lb ). • Obese women should gain on ly about 5 to 9 kg (11 to 20 lb ). • Excessive weight or excess weight gain during pregnancy increases risks for high blood pressure, diabetes, difficult delivery, and need for cesarean section. o Large -for -gestational -age: weighing more than 4 kg (8.8 lb ) at birth. o Increases mother’s long -term risk for obesity. Physical Activity During Pregnancy • Benefits of physical activity during pregnancy: improve digestion, prevent excess weight gain, low back pain, and constipation, reduce risk of diabetes and high blood pressure, and speed recovery from childbirth. • Guidelines: maximize benefits of exercise and minimize risk of injury to mother and fetus. o General: 30 minutes of carefully chosen moderate exercise per day. o Limit intense exercise. Discomforts of Pregnancy • Edema: accumulation of extracellular fluid in the tissues. o Increases medical risk s if it is associated with a rise in blood pressure. • Morning sickness: nausea and vomiting occurring during the first trimester. o Thought to be related to hormones that are released early in pregnancy. o Can be alleviated with small frequent snacks of dry, starchy foods. • Heartburn and constipation: caused by relaxation of the GI tract and crowding of the organs by the growing fetus. Complications of Pregnancy • High blood pressure: occurs in 10 % of pregnancies in U.S. o Hypertensive disorders of pregnancy: spectrum of conditions involving elevated blood pressure during pregnancy. o Accounts for more than 12% of pregnancy -related maternal deaths . o Preeclampsia and eclampsia are m ore common in mothers under 18 and over 35 years of age, low -income mothers, obese mothers, and mothers with chronic hypertension or kidney disease. o Gestational hypertension: an abnormal rise in blood pressure that occurs after the 20 th week of pregnancy and resolves within 12 weeks of birth . o Preeclampsia: a condition characterized by elevated blood pressure, a rapid increase in body weight, protein in the urine, and edema. ▪ Also called toxemia. ▪ Dangerous to the baby because it reduces blood flow to the placenta. ▪ Dangerous to the mother because it can progress to a more severe form of pregnancy -induced hypertension (eclampsia) . o Eclampsia: convulsions or seizures brought on by preeclampsia. ▪ Untreated, it can lead to coma or death. ▪ Requires bed rest and careful medical monitoring. ▪ Condition resolves after delivery. • Gestational diabetes: a condition characterized by high blood glucose levels that develop during pregnancy. o More common: obese women and those with a family history of type 2 diabetes. ▪ More frequently: Asian, African American, Hispanic/Latino, and Native American women. o Usually resolves after birth. ▪ Mother has a 35 to 60% chance of developing diabetes in the next 5 to 10 years. o Requires treatment to normalize maternal blood glucose levels. ▪ Glucose passes freely across the placenta. ▪ When the mother’s blood g lucose levels are high, the growing fetus receives extra glucose and calories. ▪ Increases risk of large for gestational age. ▪ Increased risk for difficult delivery , preterm delivery, and birth defects . ▪ Increased risk of diabetes as adults. Nutritional Needs During Pregnancy Energy and Macronutrient Needs • Energy needs: o First trimester: same as nonpregnant . o Second and third trimester: additional 340 to 452 calories/day. • Protein needs: additional 25 g above RDA or 1.1 g/kg/day. • Carbohydrate: additional 45 g to 175 g/day. o Whole grains, fruits, and vegetables. o Additional 3 g of fiber/day. • Fat: not necessary to increase total fat intake. o Additional amounts of the essential fatty acids linoleic and α -linol enic a cid. o Docosahexaenoic acid (DHA ) and arachidonic acid (ARA) are important: essential for eye and nervous system development in the infa nt. Fluid and Electrolyte Needs • Water need s increase from 2.7 L/day in nonpregnant women to 3 L/day during pregnancy. • No eviden ce that requirements are increased for potassium, sodium, and chloride than nonpregnant women . Vitamin and Mineral Needs • Calcium and vitamin D: AI for calcium is not increased during pregnancy; absorption doubles. o Can be met with foods. o Low calcium intake increases the risk of developing preeclampsia in pregnant teens, individuals with inadequate calcium intake, and women at risk for preeclampsia . o May need more vitamin D. • Folate (folic acid) and vitamin B12 o Folate is needed for the synthesis of DNA a nd cell division. o Low folate levels increase the risk of abnormalities in the formation of the neural tube which forms the baby’s brain and spinal cord . o Recommendation prior to pregnancy: increase of 400 µg daily of synthetic folic acid from fortified foods, supplements or combination o During pregnancy: RDA 600 µg/day. o Folate def iciency: can cause m acrocytic anemia in the mother. ▪ Associated with prematurity, low birth weight, and birth defects. o What a Scientist Sees: Folic Acid Fortification and Neural Tube Defects ▪ Since the initiation of folic acid fortification, the incidence of neural tube defects has been reduced by 36% in the United States and 31 to 50% on other countries where folic acid fortification is mandatory. o Vitamin B12 : essential for the regeneration of active forms of folate. ▪ Deficien cy can result in macrocytic anemia in the mother which impair s growth and cognitive development in the fetus . ▪ RDA: 2.6 µg/day. ▪ Easily met with small amounts of animal products. ▪ Vegans: must include vitamin B12 supplements or B12 fortified foods and beverages . • Iron and Zinc o Iron: RDA: 27 mg/day, 50% higher than recommended for nonpregnant women ▪ Required for the synthesis of hemoglobin and other iron -containing proteins . ▪ Iron deficiency anemia during pregnancy has been associated with low birth weight , preterm delivery , and cognitive development . ▪ Well planned diet can meet needs. ▪ Iron supplements are typically recommended. ▪ Consuming vit amin C foods or beverages along with iron containing foods enhances absorption. o Zinc: RDA: 13 mg/day for pregnant women age 1 8 and younger; 11 mg/day for pregnant women age 19 and older. ▪ Involved in the synthesis and function of DNA and RNA , and synthesis of protein . ▪ Zinc deficiency during pregnancy: associated with increased risks of fetal malformations, premature birth, and low birth weight. • Iodine o Iodine: RDA: 220 μg/day from food or supplement sources. ▪ During pregnancy there is a 50 % increase in maternal thyroid hormone production and increase in iodine lost in urine. ▪ Deficiency causes brain damage in the fetus as well as fetal goiter, hypothyroidism, and cretinism. Meeting Nutrient Needs with Food and Supplements • Energy and nutrient needs of pregnancy can be met by following the Mediterranean - style eating pattern, the DASH Eating Plan, or MyPlate . • Prenatal supplement generally recommended for all pregnant women. Food Cravings and Aversions • Most women experience some food cravings and aversions during pregnancy. • Not known why women experience cravings and aversions. o May be hormonal or physiological changes. o Psychological and behavioral factors may also be involved. • Pica: an abnormal craving for and ingestion of nonfood substances that h ave little or no nutritional value. Example: clay, laundry starch, ashes. o May be related to cultural beliefs ; protection against harmful pathogens and toxins; suppression of nausea, vomiting, and diarrhea, and contribution of micronutrients . o Risks outweigh the benefits . o Complications: iron -deficiency anemia, lead poisoning, and parasitic infections. o Anemia and high blood pressure more common in those with pica. o In newborns, anemia and low birth weight are often related to pica in the mother. Thinking It Th rough: A Case Study on Nutrient Needs for a Successful Pregnancy What Should I Eat ? During Pregnancy • Make nutrient -dense choices. • Drink plenty of fluids. • Indulge your cravings, within reason. Factors That Increase the Risks Associated with Pregnancy • Anything that interferes with embryonic or fetal development can cause a baby to be premature, too small or result in birth defects. • Developmental errors causes: deficiencies or excesses in the maternal diet, harmful substances present in the environment o r consumed in the diet, or taken as medications or recreational drugs. • Teratogen: any chemical, biological, or physical agent that causes a birth defect. • Critical period: the specific development time and rate of an organ system. • Increased risk for complic ations during pregnancy: nutritional status, age, or preexisting health problems. Maternal Nutritional Status • Before pregnancy: proper nutrition is important to allow conception and maximize the likelihood of a healthy pregnancy. o Women with reduced body f at may have abnormal hormone levels. ▪ Ovulation does not occur, and conception is not possible. o Too much body fat can also reduce fertility by altering hormone levels. • During pregnancy: maternal malnutrition can cause fetal growth retardation, low birth wei ght, birth defects, premature birth, spontaneous abortion, or stillbirth. o Effects vary depending on when during pregnancy malnutrition occurs. o May also cause changes that can affect the child’s risk of developing obesity and other chronic diseases later in life. Maternal Age and Health • Teens: still growing, so their nutrient intake must meet their needs for growth as well as for pregnancy. o Increased risk: hypertensi ve disorders . o More likely to deliver preterm and low -birth -weight infants. o Needs early medical intervention and nutrition counseling to produce a healthy baby. o Remains a major public health problem. • Pregnancy after age 35: carries additional risks. o Nutritional requirements the same as for women in their 20s. o More likely to already have one o r more medication conditions: cardiovascular disease, kidney disorders, obesity, or diabetes. o More likely t o develop gestational diabetes, hypertensi ve disorders of pregnancy , and other complications. o Higher incidence of low -birth -weight infants , pr eterm birth, stillbirth, and peri natal death . o More likely to have infants with chromosomal abnormalities, especially Down syndrome. o Frequency of twins and triplets higher among older mothers – partly due to use of fertility treatments. • Other risks: o Women with hi story of miscarriage or birth defects. o Multiple pregnancies increase nutrient needs and risk of preterm delivery . ▪ An interval of less than 18 months between pregnancies increases risk of delivering preterm or small -for -gestational age infant as well as ris k of neonatal or infant mortality . Poverty • One of the greatest risk factors for poor pregnancy outcome. o Limits access to food, education, and health care. o Higher incidence of low -birth -weight and preterm infants. o Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): federally funded program. o Provides nutrition counseling and funds to purchase nutritious foods and referrals to health and other services for low -income women who are pregnant, postpartum, or breast feeding, and for infants and children up to age 5. Exposure to Toxic Substances • Caffeine: in excess, have been associated with increa sed risks of miscarriage or low - birth -weight. o Recommendation: avoid consuming more than 200 mg of caffeine (1-2 cups of coffee) per day or 2 to 3 20 -ounce soft drinks. • Mercury in fish: consumption during pregnancy can cause developmental delays and brain damage. o Avoid varieties of fish that are highest in mercury and limit intake of low -mercury fish. • Food -born e illness: immune system is weakened during pregnancy, increasing susceptibility to and the severity of certain food -borne illnesses. o Listeria infection : results in miscarriage, stillbirth, or infection of the fetus. ▪ About one -thi rd of babies born with Lis teria infections , do not survive. ▪ Bacteria are commonly found: unpasteurized milk, soft cheeses, uncooked hot dogs and lunch meats. • Toxoplasmosis: infection caused by a parasite. o If a pregnant woman is infected, she can pass the infection to her unborn baby. o Infected babies: develop vision and hearing loss, intellectual disability, and/or seizures and some die within days of birth . o Parasite is found in cat feces, soil, and undercooked infected meat. • Alcohol: consumption during pregnancy is one of the leading causes of preventable birth defects. o Teratogen that is particularly damaging to the developing nervous system. o Indirectly affects fetal growth and development. o Fetal alcohol syndrome (FAS): a characteristic group of p hysical and mental abnormalities in an infant resulting from maternal alcohol consumption during pregnancy. o Fetal alcohol spectrum disorders (FASD s): refers to all the physical or behavioral disorders or condition s and functional or mental impairments linked to prenatal alcohol exposure. ▪ Affects 2 to 5% of all young school children in the US. o Complete abstinence during pregnancy is recommended. • Tobacco use: if a woman uses tobacco products during pregnancy, her baby will be affected before birth and throughout life. o Carbon monoxide in tobacco smoke binds to maternal and fetal hemoglobin, reducing the amount of oxygen delivered to fetal tissues. o Nicotine absorbed from any tobacco product , including e -cigarettes, is a teratogen that can affect brain development. ▪ Also constricts arteries and limits blood flow; reducing the amounts of oxygen and nutrients delivered to the fetus. o Reduces birth weight and increases the risks of stillbirth, preterm delivery, birth defects, an d early infant death. o Environmental exposure to cigarette smoke: increase the risk of having a low - birth -weight baby o Sudden infant death syndrome (SIDS) or crib death : unexplained death of an infant, usually during sleep. ▪ Higher incidence of SIDS and respi ratory problems in infants exposed to cigarette smoke both in the uterus and after birth . • Legal and illicit d rug use: certain drugs can affect both fertility and fetal development. o Prescription, over -the -counter, or illegal. ▪ Example of prescription drug: Accutane and Retin -A are derivatives of vitamin A that can cause birth defects during pregnancy. o Illegal s ubstance abuse during pregnancy is a national health issue. ▪ 4.4 % of pregnant women use illicit drugs . ▪ Marijuana and cocaine can cross the placenta and enter the fetal blood. • Cocaine is a central nervous system stimulant. Reduces the delivery of oxygen and nutrients to the fetus. • Cocaine use is a ssociated with an increased risk of miscarriage, fetal growth retardation, premature labor and delivery, low birth weight, and birth defects. • Has also been show to affect infant behavior and influence learning and attention span during childhood. Lactation • The need for many nutrie nts is greater during lactation than during pregnancy. Milk Production and Let -Down • Lactation involves: o The synthesis of milk components – proteins, lactose, and lipids. o And movement of these components through the milk ducts to the nipple. • Let -down: the release of milk from the milk -producing glands and its movement through the ducts and storage sinuses. o Triggered by hormones that are released in response to an infant’s suckling. o Prolactin: the pituitary hormone; stimulates milk production. The more the infant suckles, the more milk is produced. o Oxytocin: another pituitary hormone; causes let -down. Also stimulated by suckling. ▪ May also occur in response to just the sight or sound of an infant. o Can be inhibited by nervous tension, fatigue, or embarras sment. o Slow let -down can make feeding difficult. Energy and Nutrient Needs During Lactation • Human milk contains about 70 Calories/100 mL (160 Calories/cup). • During the first 6 months of lactation, an average infant consumes 600 to 900 mL (about 2.5 to 4 c ups/day). • Approximately 500 Calories are required for the mother each day. o From the diet. ▪ Additional 330 Calories/day above nonpregnant, nonlactating needs during the first 6 months of lactation. ▪ Additional 400 Calories during the second 6 months. o Maternal fat stores. ▪ Beginning 1 month after birth, most lactating women lose 0.5 to 1 kg (1 to 2 lbs)/month for 6 months. ▪ Rapid weight loss is not recommended. • Protein: RDA for lactation is increased by 25 g/day. • Carbohydrate, fiber, and the essential fatty acids are also higher during lactation. • Adequate hydration: need to consume about 1 L of additional water per day. • Vitamins and minerals: increased during lactation to meet the needs of synthesizing milk and to replace the nutrients secrete d in the milk. o Low m aternal intake of thiamin, riboflavin, selenium, iodine, and vitamins B 6, B 12, A, and D can affect the composition of milk. o Others, including folate, calciu m, iron, copper, and zinc levels in milk are maintained at the expense of matern al stores. Nutrition for Infants Infant Growth and Development • Developmental milestones: infants develop physically, intellectually, and socially. o Critical periods during infancy for growth and development. • Generally: an infant’s birth weight should dou ble by 4 months of age and triple by 1 year of age. • In the first year, most infants increase their length by 50%. • Growth is the best indicator of adequate nutrition. • Growth charts: can be used to compare an infant’s growth with that of other infants of the same age. o Results in a percentile ranking. o Children generally remain at the same percentile as they grow. • Failure to thrive: inability of a child’s growth to keep up with normal growth curves. o Causes: congenital condition, disease, poor nutrition, neglect, abuse, or psychosocial problems. o Critical periods during infancy for growth and development. Energy and Nutrient Needs of Infants • Human milk and commercially produced formula are designed to meet infants’ nutrient needs. • Infants may st ill be at risk for iron, vitamin D, and vitamin K deficiencies and for suboptimal levels of fluoride. • Energy and macronutrients: infants require more calories and protein per kilogram of body weight than do individuals at any other time of life. o Require an energy dense diet: high energy needs and small stomach. o Fat: 55% of energy needs during the first 6 months. 40% during the second 6 months. DEBATE: DHA/ARA -Fortified Infant Formula s • Issue: the fatty acids docosahexaenoic acid (DHA) and arachidonic acid (ARA) are essential for development of the retina and brain. Breast milk provides these fatty acids, and most infant formulas in the U .S. are fortified with them. A dvertisements suggest that these formulas provide an advant age for infant develo pment. Will feeding babies formulas fortified with DHA and ARA make them smarter and improve their vision ? • Fluid needs: need to consume more water per unit of body weight than adults. o Infants have a higher proportion of body water than adults. o Infants lose proportionately more water in urine and through evaporation. o Urine losses are high because the kidneys are not fully d eveloped. o Breast fed infants do not required additional water. • Micronutrients at risk: o Iron: deficiency is usually not a problem during the first 6 months. ▪ By 7 to 12 months old, the diet of breast fed infants should contain sources of iron. ▪ Formula fed in fants should be fed iron -fortified formula. o Vitamin D: breast milk is low. ▪ Breast fed and partially breast fed infants should supplement with 400 IU of vitamin D beginning in the first few days of life and continuing until they consume vitamin D -fortified formula or milk daily. ▪ Infants consuming 1 L/day of i nfant formula can meet their vitamin D needs . ▪ Exposure to the sun produces vitamin D . o Vitamin K: newborns receive an intramuscular injection within the first six hours of life to reduce the risk of bleeding. ▪ Little vitamin K crossed the placenta. ▪ The infant’s gut is sterile, so there are no bacteria to synthesize this vitamin. o Fluoride: important for tooth development. ▪ Breast milk is low in fluoride. ▪ Formula is made with unfluoridated water. ▪ Where the water supply is fluoridated, infant formulas should be reconstituted with it. ▪ Supplements may be necessary starting at 6 months. Meeting Needs with Breast Milk or Formula • Breast feeding is the recommend choice for the newborn of a healthy, well -nourished mother. o U.S. Health professionals recommend: exclusive breast feeding for the first 6 months of life. ▪ Breast feeding with complementary foods for at least the first year. • Infants should be fed f requently and on demand. o Breast fed infants: 10 to 15 minutes at each breast. o Well -fed infant should urinate enough to soak six to eight diapers a day and gain about 0.15 to 0.23 kg (0.33 to 0.5 lb) /week. o Nursing bottle syndrome: rapid and serious decay o f the upper teeth caused by an infant being put to bed with a bottle. • Nutrients in breast milk and formula. o Human milk is tailored to meet the needs of human infants. ▪ The composition of milk changes continually to suit the needs of a growing infant. ▪ Colost rum: the first milk, produced by the breast late in pregnancy and for up to a week after deliver. Compared to mature milk, it contains more water, protein, immune factors, minerals, and vitamins and less fat . ▪ Has beneficial effect on the gastrointestinal t ract. o Infant formulas try to replicate human milk as closely as possible. • Health b enefits of breast feeding: o Benefits for infants: ▪ Optimum nutrition. ▪ Strong bonding with the mother. ▪ Enhances immune protection. ▪ Reduces allergies. ▪ Decreases ear infections, respiratory illnesses, and asthma. ▪ Less likely to suffer from constipation, diarrhea, or chronic digestive disorders. ▪ Reduces risk for SIDS. ▪ Reduces risk for obesity, type 1 and 2 diabetes, heart disease, hypertension, and childhood leukem ia. ▪ Aids in the development of the facial muscles, speech development, and correct formation of teeth. ▪ Reduces risk of overfeeding. o Benefits for the mother: ▪ Relaxing, emotionally enjoyable interaction; strengthens bonding with infant. ▪ Less expensive. ▪ Less preparation and clean up time; always available. ▪ Causes uterine contractions that help the uterus return to its normal size more quickly after delivery. ▪ Increases energy expenditure, which may speed return to prepregnancy weight. ▪ Lowers risk of developing type 2 diabetes and breast and ovarian cancers. ▪ Improves bone density so decreases risk of hip fracture. ▪ Inhibits ovulation, lengthening the time between pregnancies but it’s not a reliable birth control method . ▪ Decreases risk of post -partum depression. ▪ Enhances self -esteem in the maternal role. • When is formula -feeding better? o Tuberculosis and HIV infection can be passed through breast milk. o Some drugs pass from the mother to the baby in breast milk. ▪ Check with physician about prescription drugs. ▪ Alcohol, cocaine, and marijuana. ▪ Nicotine. o Formula feeding requires more preparation. o It can give the mother a break and other family members can feed the infant. o Special formulas needed: pre -term infants or those with genetic abnormalities. o If an infant is too sm all or week to take a bottle, can be fed through a tube. Safe Feeding for the First Year • Sanitation of water and equipment is important to avoid bacterial contamination. o Bottle feeding: wash hands, bottles, and nipples before preparing formula. o Breast feeding: wash hands, bottles, nipples, and breast pump. • Food allergies: common in infants because their digestive tracts are immature and therefore allow the absorption of incompletely digested proteins, which trigger an immune system response. o Risk is reduced after about 3 months of age. o Many children who develop food allergies before age 3 years eventually outgrow them. o Allergies that appear after 3 years of age are more likely to be a problem throughout life. o Exclusive breast feeding for the f irst 4 to 6 months reduces an infant’s risk of developing food allergies. • Appropriate introduction of solid and semisolid food starting at 4 to 6 months old . o Recommended first food: iron -fortified infant rice cereal mixed with formula or breast milk. o Intro duce each new food for a few days, before trying another new food. • Developmentally appropriate foods: foods should be appropriate for the infant’s digestive and developmental abilities. o Solid and semi -solid foods can be gradually introduced. o Cow’s milk can be fed after 1 year of age. o Avoid foods that can cause a choking hazard. o After 6 months old, 100% f ru it juice can be fed from a cup . o Honey should not be fed to children less than 1 year of age; may contain spores of Clostridium botulism .