1. Nutrition During Pregnancy and Infancy
Chapter 11:
Nutrition During Pregnancy and Infancy

2. Chapter 11: Nutrition During Pregnancy and Infancy
LEARNING OBJECTIVES
List changes in the body during pregnancy
Understand nutritional needs, cravings and aversions during pregnancy
Be aware of factors that increase the risks associated with pregnancy
Discuss breast feeding vs. formula
Compare nutritional needs during pregnancy, lactation, and infancy

3. THINK about this – then share within a PAIR – then SHARE with the class
What do you know about nutrient needs of women during pregnancy and breast feeding?
What do you know about nutrient needs of infants?

4. Fetal development Fertilization: the union of sperm and egg
Cells divide and differentiate (specialize) for 40 weeks of gestation (pregnancy)
About a week after fertilization, the embryo implants in the lining of the uterus
Embryo - developing human from 2 to 8 weeks after fertilization; implantation – embedding of an embryo in the uterine lining
After 9 weeks, an embryo becomes a fetus

5. Fetal nourishment
Weeks 2–5: embryo receives nourishement from uterine lining
After week 5 until birth: developing baby receives nourishment from placenta
Placenta: an organ produced from maternal and embryonic tissues
Secretes hormones
Transfers nutrients and oxygen from the mother’s blood to the fetus, removes metabolic wastes
Transport via umbilical cord

6. Fetal nourishment

7. Birth weight
Full-term infants are usually born at 40 weeks and weigh 3–4 kilograms (6.5–9 pounds)
Small for gestational age: born on time but failed to grow well in the uterus
Large for gestational age: > 4 kg (8.8 lbs)
Low-birth weight infants: < 2.5 kg (5.5 lbs)
Very-low-birth weight infants: <1.5 kg (3.3 lbs)
Premature or preterm: born before 37 weeks

8. Low-birth-weight infants
Low-birth-weight and very-low-birth-weight infants require special care and a special diet so they can continue to grow and develop
© Can Stock Photo Inc. / reflekta

9. Weight gain during pregnancy
Blood volume increases by 50%
Placenta develops to nourish the fetus an to produce hormones
Amount of body fat increases to provide energy needed late in pregnancy
Uterus enlarges and muscles and ligaments relax to accommodate the growing fetus and allow for childbirth
Breasts develop in preparation for lactation (milk production and secretion)

10. Weight gain during pregnancy
The weight of an infant at birth: about 25% of total weight gain during pregnancy
The balance of weight gain:
placenta, amniotic fluid, and changes in maternal tissues, including enlargement of the uterus and breasts, expansion of the volume of blood and other extracellular fluids, and increased fat stores.

11. Weight gain during pregnancy
Healthy, normal-weight woman should gain 11–16 kg (25–35 lbs) during pregnancy
Rate of weight gain is as important as amount
Little gain is expected in the first 3 months (1st trimester), usually about 1–2 kg (2–4 lbs)
In the 2nd and 3rd trimesters, the recommended maternal weight gain is about 0.5 kg (1 lb)/week
Women who are underweight or overweight/obese at conception should, respectively, have higher and lower weight gain than normal-weight women

12. Weight gain during pregnancy
Although a similar pattern of weight gain is recommended for women who, at the start of pregnancy, are normal weight, underweight, overweight, or obese, their recommendations for total weight gain differ

13. Underweight during pregnancy
Being underweight by 10% or more at the onset of pregnancy or gaining too little weight during pregnancy increases the risk of producing a low-birth-weight baby

14. Overweight during pregnancy
Excess weight before conception or gained during pregnancy increases mother’s risks for high blood pressure, diabetes, a difficult delivery, need for a cesarean section, and having a large-for-gestational-age baby (>4 kg (> 8 lb.)
Excessive prenatal weight gain:
increased mother’s long-term risk for obesity
increased offspring’s risk for overweight/obesity

15. Overweight during pregnancy
Dieting during pregnancy is not advised!!
Excess weight should be lost before pregnancy begins or after birth and weaning

16. Physical activity during pregnancy
Moderate physical activity:
Improves digestion and prevents constipation
Improves mood and self image
Reduces stress
Prevents excess weight gain and low back pain
Reduces risk of diabetes and high blood pressure
Speeds recovery from childbirth

17. Physical activity during pregnancy
Guidelines to maximize benefits and minimize risks of injury to mother and fetus:
Women physically active before pregnancy can continue a program of about 30 minutes of carefully chosen moderate exercise per day
Women who weren’t active before pregnancy should slowly add low-intensity, low-impact activities
Because intense exercise can limit the delivery of oxygen and nutrients to the fetus, intense exercise should be limited

18. Discomforts during pregnancy
Edema: accumulation of fluid in tissues
Morning sickness: nausea and vomiting any time of day or night, usually in 1st trimester
Eat small, frequent snacks of dry, starchy foods
Heartburn
Limit high-fat foods; avoid heartburn-causing substances; eat small, frequent meals; remain upright after eating
Constipation and hemorrhoids
Maintain moderate level of physical activity and consume plenty of fluids and high-fiber foods

19. Discomforts during pregnancy

20. Concept check
How are nutrients and oxygen transferred from mother to fetus?
How does a mother’s weight gain during pregnancy affect the health of her child?
Why do heartburn and constipation tend to increase later in pregnancy?

21. Pregnancy macronutrient needs
1st trimester: energy needs not increased above non-pregnant levels
2nd and 3rd trimesters: 2-3 food servings more
Protein: increased by 25 g, or 1.1 g/kg/day, for the Carbohydrate: increased by 45 g, to 175 g/day
Fiber: increased by additional 3 g of fiber/day
Fat: increased essential fatty acids and long-chain polyunsaturated fatty acids
Same distribution of calories from protein, carbohydrate, and fat

22. Energy and macronutrient recommendations
The percentage increase above non- pregnant levels in the recommended daily intake of energy, protein, carbohydrate, fibre, essential fatty acids, and water for a 25-year-old pregnant woman in her 3rd trimester.

23. Pregnancy fluid & electrolyte needs
Water: increased to 3 L/day during pregnancy (from 2.7 L/day in nonpregnant women)
Electrolytes: no evidence that requirements for potassium, sodium, and chloride are different

24. Pregnancy micronutrient needs
The percentage increase in recommended micronutrient intakes for a 25-year-old woman during the third trimester of pregnancy.

25. Pregnancy vitamin & mineral needs
Calcium: RDA not increased because calcium absorption doubles
Needed for teeth and bones
From dairy, calcium-rich vegetables, fortified foods, supplements
Vitamin D: RDA = 600 IU (15 μg/day), the same as for non-pregnant women
Needed for absorption of calcium
From fortified foods, supplements, sunlight
Deficiencies most common in dark-skinned women

26. Pregnancy vitamin & mineral needs
Folate: RDIA during preganacy – 600 µg/day
According to Public Health Agency, Canada:
All women capable of becoming pregnant should take multivitamin supplements with 400 µg of folate per day, in addition to dietary sources such as dark leafy greens, legumes and orange juice
For synthesis of DNA, cell division, neural tube closure 21–28 days after conception; prevention of megaloblastic (macrocytic) anemia, premature births, and low birth weight

27. Folate fortification In 1998, the Canadian
and United States governments began requiring the addition of folic acid to pasta and other enriched grain products in an effort to increase the folic acid intake in women of childbearing age, with the goal of reducing the incidence of
neural tube defects.
Because high folic acid can
mask the symptoms of vitamin
B12 deficiency, the amount
added to enriched grains was
kept low enough to avoid this problem.

28. Pregnancy vitamin & mineral needs
Vitamin B12: RDA is 2.6 µg/day
For regeneration of active forms of folate, prevention of megaloblastic anemia
From animal products, fortified foods, supplements
Vegan mothers require vitamin B12 supplements or fortified foods

29. Pregnancy vitamin & mineral needs
Iron: RDA is 27 mg/day (50% higher than for non-pregnanat women)
For synthesis of iron-containing proteins (hemoglobin), prevention of iron-deficiency anemia
From red meat, leafy greens, fortified foods, supplements
Iron absorption can be increased by vitamin C containing foods
Zinc: RDA is 13 mg/day (age <18); 11 mg/day (age >19)
For synthesis and function of DNA and RNA and synthesis of proteins, prevention of fetal malformations, premature birth, and low birth weight
Best absorbed from red meat

30. Meeting energy and nutrient needs during pregnancy
The Public Health Agency of Canada and the Sensible Guide to a Healthy Pregnancy recommend:
Fruits and vegetables, particularly dark green and orange ones
Whole grains
Milk (250 mL) and milk alternatives
Fish, chosen wisely to minimize exposure to mercury and bacteria
Diet low in added sugar, salt and fat
Zinc, iodine,
and calcium
are needed for normal growth and
development.

31. Sensible guide to healthy pregnancy

32. Meeting energy and nutrient needs during pregnancy
The Sensible Guide to a Healthy Pregnancy also recommends:
Two to three more food guide servings per day
Multivitamins with iron and 0.4 mg of folate per day in addition to a carefully planned diet

33. Prenatal supplements
Andy Washnik

34. Food cravings & aversions
Common cravings
Ice cream, sweets, candy, fruit, fish
Pica: craving for and ingestion of nonfood substances (clay, laundry starch, ashes) with little or no nutrition
Common aversions
Coffee, highly seasoned foods, fried foods
Unknown cause, possibly hormonal or physiological (for example, taste and smell changes), psychological, or behavioral changes

35. Pica Some women crave white clay (kaolin), during pregnancy
Eating kaolin is also a traditional remedy for morning sickness and may be related to cultural beliefs and traditions
Pica is also believed to be triggered by stress, nutrient deficiencies, and anxiety.

36. What should I eat (during pregnancy)?
Make nutrient-dense choices
Drink plenty of fluids
Indulge your cravings, within reason

37. Concept check
What snack could a pregnant woman add to her day to meet her increased calorie and protein needs?
Why isn’t the recommendation for dietary calcium increased during pregnancy?
Why are iron supplements recommended during pregnancy?

38. Increased risks during pregnancy
The embryo and fetus are vulnerable to damage because cells are dividing rapidly, differentiating, and moving to form structures
Developmental errors can be caused by deficiencies or excesses in maternal diet and by harmful substances in the environment, diet, medications, or recreational drugs
Teratogen: agent that causes a birth defect during a critical period in development

39. Critical periods of development

40. Increased risks during pregnancy
Some women are at increased risk for complications during pregnancy due to their:
Nutritional status
Age
Pre-existing health problems
Exposure to harmful substances

41. Maternal nutritional status
Before pregnancy:
Importance of proper nutrition for the maintenance of normal body fat, hormone levels and fertility
During pregnancy, malnutrition can lead to:
growth retardation, low birth weight, birth defects, premature birth, spontaneous abortion, stillbirth
increase child’s risk of developing chronic diseases such as cardiovascular disease, high blood pressure, diabetes mellitus, obesity and osteoporosis
future food preferences of an infant

42. Dutch famine effects on pregnancy
During World War II, an embargo on food transport to the Netherlands (winter 1944–1945) led to the average food intake per person < 1,000 kilocalories/day
As a result:
pregnant women gave birth to smaller babies
in adulthood, the affected babies were more likely than others to have diabetes, heart disease, obesity, and other chronic diseases

43. Teenage pregnancy
Nutrient intake must meet their needs for growth and for pregnancy
Increased risk of hypertensive disorders of pregnancy and delivering preterm and low-birth-weight babies
May stop growing themselves

44. Teenage pregnancy
Nutrient needs of pregnant teens differ from those of pregnant adults
The percentage increase in micronutrient needs above non-pregnant levels is shown for 14- to 18-year-olds during their second and third trimesters of pregnancy.

45. Pregnancy over age 35 More likely to:
have preexisting conditions (cardiovascular disease, kidney disorders, obesity, or diabetes) which increase risks associated with pregnancy
develop gestational diabetes, hypertensive disorders of pregnancy, and other complications
have low-birth-weight infants and chromosomal abnormalities, especially Down syndrome
have twins and triplets with increased nutrient needs and preterm delivery

46. Increased risks during pregnancy
A woman who has had
many miscarriages is more likely to have another
one child with a birth defect has increased risk for defects in subsequent pregnancies
<18 months between pregnancies has increased risk of delivering a small-for-gestational age infant
only 3 months between pregnancies has increased risk of a preterm infant and neonatal death

47. Toxic substances during pregnancy
Caffeine in excess associated with increased risk of miscarriage or low birth weight
Limit caffeine to <300 mg/day (two 240-mL cups of coffee/day)
Mercury in fish can cause developmental delays and brain damage
Avoid varieties of fish high in mercury; limit fish with lower amounts mercury
Fish - source of lean protein, omega-3 fatty acids, iodine

48. Sources of caffeine

49. Food safety during pregnancy

50. Food-borne illness during pregnancy
Immune system weakened during pregnancy; increased number and severity of infections
Listeria infections often result in miscarriage, premature delivery, stillbirth, or fetal infection
bacteria commonly found in unpasteurized milk, soft cheeses, and uncooked hot dogs and lunch meats
Toxoplasmosis parasitic infections: babies can develop vision and hearing loss, intellectual disability, seizures
parasite found in cat feces, soil, and undercooked infected meat

51. Alcohol during pregnancy
A leading cause of preventable birth defects
Teratogen that damages nervous system
Affects fetal growth and development because it reduces blood flow to the placenta
Can impair maternal nutritional status
Can cause fetal alcohol syndrome (FAS): physical and mental abnormalities in an infant resulting from maternal alcohol consumption during pregnancy

52. Alcohol during pregnancy: FAS
Facial characteristics associated with FAS: a low nasal bridge, short nose, distinct eyelids, and thin upper lip
Newborns with FAS may be shaky and irritable, with poor muscle tone
Other problems include heart and urinary tract defects, impaired vision and hearing, and delayed language development
Below-average intellectual function is the most common and most serious effect

53. Alcohol during pregnancy
Other, less severe but more common alcohol-related problems include:
Alcohol-related neurodevelopmental disorder (ARND) characterized by mental impairments
Alcohol-related birth defects (ARBD) – malformations in the skeleton or major organ systems
Complete alcohol abstinence is recommended during pregnancy!!!

54. Tobacco and certain drugs
Tobacco, marijuana and cocaine should be avoided during pregnancy
These drugs can cross placenta and lead to profound negative effects on the offspring’s development and future health

55. High blood pressure
About 5% to 10% of pregnant women experience hypertension during pregnancy
Hypertension during pregnancy are due to:
Chronic hypertension present before pregnancy
Gestational hypertension (rise in blood pressure after the 20th week of pregnncy)
Preeclampsia: characterized by elevated blood pressure, a rapid increase in body weight, protein in urine and edema
Dangerous to the mother and the baby

56. Gestational diabetes High glucose levels developing during pregnancy
Increased risk (20% to 50%) of diabetes within next 5 to 10 years (mother)
Babies large for their gestational age
increased risk for difficult delivery, abnormal glucose at birth, an future diabetes

57. Concept check
Why does the effect of a given teratogen vary, depending on when a fetus is exposed to it?
How does malnutrition during pregnancy affect the child’s health at birth and later in life?
Why are requirements for some nutrients different in pregnant teenage girls than in pregnant adult women?
How much alcohol can be safely consumed during pregnancy?

58. Infant growth and development
Growth is the best indicator of adequate nutrition in an infant
Birth weight should double by 4 months and triple by 1 year
Most infants increase length by 50%
Growth charts: compare weight, length, or head circumference to the population
Ranking, or percentile, indicates where the infant’s growth falls in relation to population standards

59. Growth charts for Canada

60. Infant growth
Not following the established growth curve or a sudden change in growth pattern could indicate overnutrition or undernutrition
Failure to thrive - inability of a child’s growth to keep up with normal growth curves
Caused by biological, environmental (e.g., nutrition) or psychosocial problems
Can permanently affect growth, development, learning, behavior, health

61. Developmental milestones
Adequate nutrition is essential for the physical, intellectual and social development
Rapid growth and high metabolic rate during infancy increase need for energy, protein, and vitamins/minerals intake
Infants may be at risk of developing vitamin D and K, iron and fluoride deficiencies

62. Nourishing a developing infant
© Can Stock Photo Inc. / Vishnena
© Can Stock Photo Inc. / arekmalang © Can Stock Photo Inc. / fanfo © Can Stock Photo Inc. / diego_cervo

63. Infant nutrient needs Energy recommendations for 3 age groups
0 to 3 months, 4 to 6 months, and 7 to 12 months
Nutrient recommendations for 2 age groups
0 to 6 months and 7 to 12 months
Require an energy-dense diet
1st 6 months: about 55% of energy intake as fat
2nd 6 months: about 40% of energy intake as fat
These percentages are far higher than the 20–35% of energy from fat recommended for adults

64. Energy and macronutrient needs
The total amount of energy required by an infant < the amount needed by an adult
When expressed as kilocalories per kilogram (kcal/kg) of body weight, however, infants require about 3 x more energy than an adult male

65. Infant nutrient needs
Water: need to consume more water per unit of body weight than do adults
Healthy infants who are exclusively breast fed do not require additional water
Diarrhea and vomiting – fluid replacement needed
Iron:
AI from 0–6 months = 0.27 mg/day
RDA for 7–12 months = 11 mg/day; formula-fed infants should be fed iron-fortified formula

66. Infant nutrient needs Vitamin D:
Breast-fed and partially-breast-fed infants should be supplemented with 400 IU (10 µg)/day until consuming about 1 L (4 cups) of vitamin D-fortified formula/milk daily
Formulas contain at least 10 µg vitamin D/L
Light-skinned infants synthesize enough vitamin D after 15 min of sun exposure/day
dark-skinned infants may require longer exposure

67. Infant nutrient needs Vitamin K: Fluoride:
All newborns should receive a mg injection
Fluoride:
Breast-fed infants, infants on pre-mixed formula and on formula mixed with low fluoride water – often given fluoride supplements beginning at 6 month of age

68. Breast feeding
Breast feeding is the recommended choice for newborns of healthy, well-nourished mothers
Canadian health professionals recommend:
Exclusive breast feeding for 6 months and breast feeding with complementary foods for at least 1 year and as long thereafter as mutually desired
Lactation can continue as long as suckling is maintained
Breast-feeding on demand

69. Breast-feeding vs. formula feeding
© Can Stock Photo Inc./ Feverpitched
Custom Medical Stock Photo, Inc./K.L.Boyd DDS
The World Health Organization recommends
breastfeeding for two years or more
The nursing bottle syndrome

70. Breast milk
Colostrum: produced by the breast for up to a week after delivery
Has beneficial effects on the gastrointestinal tract
Nutrients supplies meet the infant’s needs until mature milk production begins
Contains more water, protein, immune factors, minerals, and vitamins and less fat than mature milk
Mature breast milk: contains an appropriate balance of nutrients in easily-digested forms

71. Breast milk vs. formula

72. Benefits of breast milk
Formula can never exactly duplicate human milk composition
Immune system cells, antibodies, enzymes, and other substances pass to the child, providing immune protection
Growth factors and hormones promote maturation of the infant’s gut and immune defenses and enhance digestion
Physical, emotional, and financial advantages

73. Benefits of breast feeding
© iStockphoto.com/SelectStock

74. When is formula better?
Some substances can be passed to a baby in breast milk
Tuberculosis bacterium, HIV, nicotine, some medications, alcohol, cocaine, marijuana
Family members can share responsibility
Special formulas available for preterm infants and those with genetic abnormalities

75. Alcohol & breast feeding
Alcoholic mothers counseled not to breast feed
Occasional limited alcohol is probably not harmful if alcohol intake is timed to minimize amount present in milk when infant is fed
After consuming a single alcoholic drink, wait at least 4 hours before breastfeeding
Alternatively, milk can be expressed before consuming the drink and fed to the infant later

76. Safe infant feeding
Whether infants are breastfed or formula-fed, care must be taken to ensure that their needs are met and their food is safe

77. Safe infant feeding
Breast milk that is not immediately fed to the baby can be kept refrigerated for 24 to 48 hours
Warming breast milk in a microwave is not recommended because microwaving destroys some of its immune properties and may result in dangerously hot milk
The best way to warm milk is by running warm water over the bottle

78. Food allergies
Common in infants due to immature digestive tracts that allow absorption of incompletely digested proteins, triggering immune response
Risk of developing food allergies reduced after age 3
Many children who develop food allergies before age 3 eventually outgrow them
Allergies appearing after 3 years more likely remain

79. Reducing risk of food allergies
Exclusive breast feeding for first 4–6 months
Appropriate introduction of solid and semisolid foods
First: iron-fortified infant rice cereal mixed with formula or breast milk
Then: other grains can be introduced
Last: wheat cereal
Each new food should be offered for a few days without the addition of any other new foods

80. Infant feeding
Solid and semisolid foods can be gradually introduced starting at 4–6 months
Foods that can easily lodge in the throat should not be offered to infants or toddlers
Cow’s milk should never be fed to infants
At 1 year of age, whole cow’s milk can be offered
At 2 years of age, reduced-fat or low-fat milk can be used

81. Infant feeding
Fruit juice can be fed from a cup when an infant is 9–10 months old
Excess of apple and pear juices should be avoided; contain sorbitol that can cause diarrhea
Added sugars - in moderation
Unpasteurized honey should not be fed to children <1 year old
May contain Clostridium botulinum causing botulism poisoning

82. Concept check
What does it mean if a child whose birth weight was in the 50th percentile is now in the 30th percentile for growth?
Why do infants need more fat than adults?
Why is breast milk the best choice for healthy mothers and babies?
When can solid food be introduced into an infant’s diet?

83. What are similarities and differences between:
Nutrition in teen and adult pregnancy?
Nutrition in pregnant and non-pregnant women?
Nutrition in breast-feeding and non-breast-feeding women?
Colostrum and mature breast milk?
Breast milk and formula?

84. Debate
Will feeding babies DHA-fortified infant formulas make them smarter and see better?

85. Nutrition in the news Plastic in infant formula Plastic baby bottles
Breast feeding in public
Laws to support breast feeding

86. Checking student learning outcomes
What advice could you give to a loved one who is thinking of getting pregnant?
What advice could you give to a loved one who is thinking of breast feeding?
What advice could you give to a loved one about feeding his/her infant?

87. Lactation Synthesis of milk components AND
Stimulated by pituitary hormone prolactin
AND
Let down: release of milk from milk-producing glands and movement through the milk ducts to the nipple
Stimulated by pituitary hormone oxytocin
Inhibited by nervous tension, fatigue, or embarrassment

88. Lactation

89. Lactation: Energy and nutrient needs
Human milk contains about 70 kilocalories/100 mL (160 kilocalories/cup)
During 1st six month of infancy: about 500 kilocalories are required from the mother each day
Because some energy comes from mother’s fat, energy intake during lactation should be lower than during pregnancy

90. Nutrient needs during lactation
1st 6 months: additional 330 Calories/day
2nd 6 months: additional 400 Calories
Protein: RDA increased by 25 g/day
Higher intakes of total carbohydrate, fiber, essential fatty acids, several vitamins, minerals
Water: additional 1 liter/day
Some energy and nutrients from maternal stores

91. Lactation: energy and macronutrient needs
The percentage increase in energy and macronutrient recommendations for a 25-year-old woman during the third trimester of pregnancy and the first six months of lactation.

92. Lactation: micronutrients needs

93. Concept check What causes milk let-down?
Where does the energy for milk production come from?
Why is the recommended calcium intake for a new mother not increased while she is lactating?

94. COPYRIGHT
Copyright © 2014 John Wiley & Sons Canada, Ltd. All rights reserved. Reproduction or translation of this work beyond that permitted by Access Copyright (The Canadian Copyright Licensing Agency) is unlawful. Requests for further information should be addressed to the Permissions Department, John Wiley & Sons Canada, Ltd. The purchaser may make back-up copies for his or her own use only and not for distribution or resale. The author and the publisher assume no responsibility for errors, omissions, or damages caused by the use of these programs or from the use of the information contained herein.