PERINATAL NUTRITION Nutrition during pregnancy and lactation Nutrition during infancy. Rama Bhat, MD. Department of Pediatrics, University of Illinois Hospital Chicago, Illinois. Nutrition During Pregnancy Improved maternal nutrition benefits both mother and infant. Maternal nutrition has a major influence on birth weight. 1
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FETAL ORIGINS OF ADULT DISEASE DEVELOPMENTAL PLASTICITY A PHENOMENA BY WHICH ONE GENOTYPE CAN GIVE RISE TO A RANGE OF DIFFERENT PHYSIOLOGICAL OR MORPHOLOGICAL STATES IN RESPONSE TO DIFFERENT ENVIRONMENTAL CONDITIONS DURING DEVELOPMENT. Birth Weight as an Indicator of Risk a) Low birth weight has high risk for coronary heart disease b) Higher risk for hypertension 3
Godfrey and Barker, 2001 Godfrey and Barker, 2001 4
Godfrey and Barker, 2001 Weight gain recommendations for pregnancy BMI(Weight for height) Low BMI ( <19.8 ) Normal BMI (19.8-26.0) High BMI (26.0-29.0 ) Obese (BMI > 29.0) Recommended gain 12.5-18 kg (28-40 lbs) 11.5-16 kg (25-35 lbs) 7-11.5 kg(15-23 lbs) 6 + kg (15 + lb.). BMI = ( Wt. In kg./ht. In m 2 ) National Academy of Sciences 1990. 5
RDAs of Nutrients during Pregnancy Non-Pregnant Pregnant Energy(Kcal) 2200 2500 Protein(g) 44-50 60 Calcium(g) 0.8 1.2 Iron(mg) 15 30 Folate(mcg) 180 400 Zinc(mg) 12 15 Phosphorus(mg) 800 1200 Vitamin D (mg) 5 10 6
NUTRITION DURING PREGNANCY Energy Requirement Cost of extra work during pregnancy has been estimated 85,000 calories. 41,000 calories for protein and fat stored in products of conception. 36,000 calories from increased O 2 consumption. 8,000 calories to convert dietary to metabolizable energy. CALCIUM METABOLISM IN PREGNANACY 99% of calcium is in the skeleton Total body calcium: 1200 grams. 1.0 % of calcium is in the ECF. Calcium is essential for: nerve conduction muscle contraction blood clotting membrane permeability 7
CALCIUM METABOLISM IN PREGNANACY Calcium requirements increase by 33 % during pregnancy. Net transfer across placenta is about 25-30 grams. Calcium transfer is active. RDA for calcium during pregnancy is 1200 mg. IRON METABOLISM IN PREGNANCY Iron is needed for: Expansion of red cell mass. The fetus and placenta Replace the blood loss at delivery 8
IRON METABOLISM IN PREGNANCY Iron requirements double during pregnancy Estimated total pregnancy iron needs is 1000 mg Mother transfers about 200-300 mg of iron to the fetus. Iron absorption during pregnancy increases to 20-40 %. Iron deficiency in the mother does not lead to iron deficiency in her infant ADVERSE EFFECTS OF IRON DEFICIENCY Mother: Fatigue Leucocyte function Tolerance at delivery Preterm delivery ( OR 1.9) Neonate: Low birth weight Neonatal death(developing countries) 9
Vitamins Folic acid: helps to produce additional blood cells helps to support rapid growth of placenta and fetus (needed for DNA) Deficiency increases: NTD (Meningomyelocele and anencephaly). Low birth weight Prematurity 10
VITAMINS Folic acid: Supplementation decreases NTDs (3.6-1.0 %). In USA alone 2000-3000 infants are born with NTDs. Worldwide incidence 300-400,000/yr. 11
MRC VITAMIN STUDY Randomized control trial Double blind using a placebo Four treatment groups A. Mineral + folic acid B. Mineral + Folic acid + M.V. C. Mineral + Placebo D. Mineral + MV (- Folic acid) Comparison: A + B vs C + D Folic acid effect B + D vs A + C Effect of other vitamins MRC Vitamin Study Relative Risk = 0.29 (95% CI 0.12-0.71, p< 0.001) 5 4 21/602 (3.5%) 3 NTD risk (%) 2 6/593 (1.0 %) NTD risk (%) 1 0 A+B WITH FOLIC ACID C+D WITHOUT FOLIC ACID 12
RECOMMENDED COMPOSITION OF MULTIVITAMIN AND MINERAL SUPPLEMENTS FOR PREGNANT WOMEN Mineral Calcium Copper Folate Iron Vitamin B 6 Vitamin D Zinc Requirement 250 mg 2 mg 300 ug 30 mg 2 mg 5 ug 15 mg National Academy of Sciences 1990. Pregnancy and Physical Activity Source of considerable debate Outcome of well conducted studies Increased activity does not result in increased absorption. Active women have less difficulty during labor. Infants of very active women were smaller. Advice: Exercise in moderation during 3rd trimester. 13
FOOD CRAVINGS AND AVERSIONS Dietary changes during pregnancy: Some by advice of the physician. Some by folk medical beliefs. Some by change in appetite. Food cravings: Sweets and dairy products. Aversions: Alcohol, coffee and meats. FOOD CRAVINGS AND AVERSIONS Cravings and Aversions are not necessarily deleterious. 14
SOCIAL AND ENVIRONTMENTAL FACTORS Drug abuse HIV infection DRUG ABUSE DURING PREGNANCY Prevalence 10-15%. Commonly Abused drugs: * Cocaine * Heroin * Marijuana * Tobacco * Alcohol * PCP 15
ALCOHOL ABUSE Increased incidence of addiction (18 52%). Poor maternal nutrition. Fetal Alcohol Syndrome ( 1.9-2.2 /1000) CNS involvement growth retardation fetal dysmorphology 16
HIV INFECTION Nutritional Deficiency with AIDS protein caloric Malnutrition Zinc and selenium deficiency Calcium and Magnesium Vitamin A, B6, B12, C, E deficiency BABY BUILDING BASICS Choose food from all FIVE food groups. Aim of 25-35 lbs weight gain. Add 300 calories/day to your diet. Add calcium supplement (1000 mg/day). Add daily prenatal vitamins. Avoid alcohol and smoking. Do not eat raw or uncooked foods. Drink 64 ounces of fluid. 17
Nutritional Assessment Dietary Evaluation &Recommendation Access to Registered Dietician Evaluation Nutritional Status Weight for Height Eating Habits. Modification of the Diet to Existing Medical Condition Benefits of Maternal Nutrition Services Preconceptional Prenatal Postpartum Improves overall maternal health Allows time to change habits Allows reduction of risk factors prior to conception Improves birth weight,may reduce perinatal morb. Impr. Maternal health & comfort, incr. initiation of breast feeding. Increases breastfeeding success improves mat. nutrition. Provides opportunity to promote healthful eating for entire family. 18