Maternal Nutrition - Micronutrients WV CW Handout

Carol Williams
IFCcic & World Vision
Iodine
Infant Feeding Consortium cic.
Iodine deficiency during pregnancy

hinders development of foetus and
results in birth of cretins and infants
with severe mental retardation. It is not
reversible.
Maternal Nutrition: Micronutrients

Iron (& Zinc)
Vitamin A
Vitamin D
Iodine
Folate & B12,
Aug-11
Carol Williams
In areas where iodine

deficiency is endemic,
pregnant women need
iodine supplements
1
Carol Williams
Carol Williams
If woman has reasonable iron stores (>500mg)

no need for extra iron during pregnancy,
because the 680mg needed should be covered
by stores and lack of menstrual losses.
Universal Salt Iodization (USI) was agreed

strategy WHO 1994.
But evidence pregnant and lactating women,
and children <2yrs might not be adequately
covered where USI not fully implemented
In areas low access to USI (<20%) vulnerable
groups should have supplement or fortified
foods.
Carol Williams
Carol Williams
Iron needs during pregnancy
Reaching Optimal Iodine Nutrition in Pregnant

and Lactating Women and Young Children
Aug-11
Aug-11
UK DRV, FAO 2002
But good iron stores are rare, and difficult to replenish

stores from diet once pregnant.
Many women given iron supplements in second half
of pregnancy. 100mg iron/day. (more if women
anaemic). Do mothers take the tablets?
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3
Aug-11
Carol Williams
Carol Williams, IFC cic
Carol Williams
BUT some need for caution with Fe

Routine prescription of iron
supplementation in women with
sufficient dietary sources of iron is not
advised and may cause problems with
zinc absorption and copper
metabolism
AND in areas with high prevalence of
malaria it increases the morbidity and
mortality from malaria.
Aug-11
Carol Williams
Carol Williams
Maternal & Child Nutrition: Infant and Young

Child Feeding Advocacy Course. Phnom
Penh, Cambodia
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5
Aug-11
Carol Williams
Weekly Iron-folic Acid Supplementation

(Wifs) In Women Of Reproductive Age.
CDC: Global Health Programs: Global Initiative to

Eliminate Folic Acid-preventable Neural Tube Defects
WHO Position statement 2009
300,000 neural tube defect-affected pregnancies

annually
Decline in OECD countries in part because of
fortification, and use of supplements.
Is a significant problem in many parts of the
world, but lack monitoring data to quantify.
pregnant women with a serum folic acid level < 3
ng/ml was highest among pregnant women in Sri
Lanka (57%), followed by India (41.6%), Myanmar
(13%) and Thailand (15%) WHO 1992.
WHO usually recommends daily

supplementation 60 mg iron+ 400 ug folic
acid during pregnancy and the first 3 months
postpartum.
In populations with >%20% anaemia in WCBA,
Wifs should be considered. 60 mg iron as
ferrous sulphate (FeSO4.7H2O) and 2800 g
folic acid,
Aug-11
1. Non-meat eating mothers- Answer
Iron infants needs 0-6m

Infants early iron needs met from body stores.
Premature baby less stores= given iron
supplement
Delayed cord clamping more iron for infant
Maternal iron deficiency during pregnancy

moderate <10g/dl Hb infants iron stores at birth
not affected
severe <7g/dl Hb infants iron stores at birth small,
association low Hb and prematurity
Iron absorption increases as iron status falls

Aug-11
Iron and Zinc:

If had iron supplements during pregnancy, (or good
dietary iron and Zn), ExBf <6m will provide enough
iron for healthy term infant.
If had delayed cord clamping even more iron and
zinc available for baby.
If not had supplements, and/or baby is LBW or
preterm, infant may need supplements <6m.
For all babies iron (+ Zn) rich complementary foods
important after 6 months
Aug-11
1. Not worried about exbf.

2. Questions: Find out about
Fe supplements during pregnancy
previous history of anaemia
cord clamping.
3. Suggestions:
Child will need iron-rich complementary
foods from 6 months.

Penh, Cambodia
10
Exclusive Breastfeeding and iron status in term

babies. Dehli, 2003-4 Raj et al, 2008
1. Non-meat eating mothers- Answer
Aug-11
Hb (g/dl)
14 weeks
6 months
Serum ferritin ng/ml
14 weeks
6 months
Non anaemic
mums
Anaemic
mums
12.5 +/- 0.6

11.5 +/- 0.5
11.6 +/- 0.9

11.2 +/- 0.5
54.6 +/- 9.7

17.8 +/- 6.5
55.0 +/- 8.5

17.7 +/- 6.4
Excl Bf babies of anaemic (Hb 7-10.9 g/dl) and non-anaemic

(Hb>11g/dl) did not develop iron deficiency or iron
deficiency anaemia by six months of age.
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Aug-11
Carol Williams
Zinc - Adequacy for infant 0-6m
Iron, Zinc and Copper concentrations in

breastmilk are independent of maternal mineral
status
Domellof et al. AM J Clin Nut 2004;79:111-5.
Premature or LBW most at risk, because

smaller stores. May benefit from Zn
containing supplements.
Some evidence that chronically low
maternal zinc intakes associated with lower
B.milk Zinc. Need appropriate
complementary foods at 6M.
Concern poor immune function with low Zn
intakes.
Aug-11
Research examining breastmilk samples from

Sweden and Honduras at 9 mnths
Found no relationship Fe, Zn, Cu
concentrations and maternal mineral status.
Suggest active transport in the mammary
gland.
13
Aug-11
Currently, there is no evidence available

to assess the potential benefits or harms of the
use of multiple micronutrient powders for home
fortification of foods consumed by pregnant
women with regard to maternal and infant health
outcomes.
Thus the routine use of this intervention during
gestation is not recommended as an alternative
to iron and folic acid supplementation in
pregnancy (strong recommendation).
Vitamin B12
Cobalamin
Synthesised by bacteria and algae.
Main food source - animal products.
In some communities, contamination of food stuffs by
micro-organisms is also a significant source.
Answer:
If do not eat meat, milk, eggs, cheese or
other dairy products, need B12
supplements.
Vegans in hygienic households at
particular risk
Aug-11
16
Vitamin A deficiency affects about 19 million pregnant

women and 190 million preschool-age children, mostly in Africa
and South-East Asia.
Vitamin A supplementation for neonates, infants 1-5 months
or postpartum women is not recommended as a public
health intervention to reduce infant morbidity and mortality
(strong recommendation). Evidence for benefit only
moderate, side effect of bulging fontanelles, evidence for
other critical outcomes low.
In areas where vitamin A deficiency is a public health
problem Vitamin A supplementation in pregnant women,
IYC 6-59 months age is recommended as a public health
intervention to reduce child morbidity and mortality (strong
recommendation).
ExBF fine : Vit A content of Breastmilk from Vit Adeficient mother is sufficient to meet infants
basal needs for 6 months.
Will need Vit A-rich complementary foods after
6m.
Questions:
Did mothers have Vit A supplement pre-pregnancy?
Suggestions:
Supplementing mother can raise Vit A content of
BM. Can be through diet or supplements.
Infant supplementation programme

Penh, Cambodia
2011 WHO Guidance on Vitamin A
2. Answer. Vitamin A deficient area?
14
What about the Vegan Mother?
2011 WHO Guidance on use of multimicronutrient powders for pregnant women
Aug-11
17
Carol Williams
3. Undernutrition and Poverty: thin mothers high

physical labour?
3. Answer: Undernutrition and Poverty?
Energy.
Babys demands will drive breastmilk
production.
Fat content may be lower, but if demand
fed, baby will get all the energy needed.
Mean energy content milk can vary from
62-80kcal/100ml due to variations in fat
content.
No evidence protein concentration affected
by maternal nutrition.
ExBF OK Better than alternatives.

Poverty = likely high risk environment where
protective effects breastfeeding essential, and
unable to afford formula or conditions to make up
safely.
Some evidence that increasing dietary fat increases
breastmilk fat content, with threshold level between
37-60gfat/day. Emmett.
Studies of giving supplemental foods inconclusive
effect on milk (better for mother)
Suggestions:
reducing labour and increasing diet and intrahousehold distribution while breastfeeding.
Aug-11
19
Aug-11
4. Repeated pregnancies: several children <5yrs. C

Close pregnancies leads to depletion of maternal
nutrient and energy reserves.
Problem Nutrients: Energy, Iron, folic acid,
Recuperative interval (when not pregnant or BF) of
6m to replace and build up nutrient and energy
reserves
Mothers undernourished at first pregnancy, unlikely
to achieve repletion.
Well nourished mothers <18m interval nutrition
status may be compromised.
Adolescents need increased food intake to
accommodate adolescent growth spurt and establish
energy and nutrient reserves for pregnancy and
lactation.
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ExBf? Depends.
Questions: Supplements/diet during pregnancy?
If received Fe, Zn and folic supplements during
pregnancy or good diet, breastmilk OK
If not youngest infant may need micronutrient
supplements <6m
Suggestions:
Child needs nutrient rich complementary foods
after 6m.
Mother needs to eat sufficient calories and continue
supplements to build up reserves for future health
or pregnancies.
Aug-11

Penh, Cambodia
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Wagner, Greer Pediatrics 2008
Close pregnancies leads to depletion of

maternal nutrient and energy reserves.
Recuperative interval (when not pregnant or
BF) of 6m to replace and build up nutrient and
energy reserves
Adolescents need increased food intake to
accommodate adolescent growth spurt and
establish energy and nutrient reserves for
pregnancy and lactation.
Vitamin D recommendation USA
Nutrient Reserves and breastfeeding.
Aug-11
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4. Answer: Repeated pregnancies
King. J Nutr 2003;133:1732S-6
Aug-11
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2008American Academy of Pediatrics:

All infants 10mcg/day (400iu) beginning first few
days after birth unless/until infant takes >1 litre
vitamin D fortified formula or whole milk. (Based on
one teaspoon cod liver oil)
Aug-11
24
Carol Williams
Current Vitamin D recommendations may not be enough: 2010
Answer 5. Babies of covered mothers who rarely go

outside.
May Mulligan et al. Obstetrics
Vitamin D deficiency in pregnancy worldwide

prevalence 18-84%
Studies show 400iu (10mcg) in pregnancy may not be
enough need 1000iu
To increase levels in breastmilk need 1000iu (400iu
not enough)
At risk groups:
1. Northern latitudes esp winter or spring
2. Limited sun exposure
3. Dark skin
4. Obesity
5. Extensive clothing cover
6. Aging
7. Malabsorptive syndromes- eg inflam bowel
Aug-11
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Nutritional Adequacy of Exclusive

Breastfeeding for the Term Infant
during the first six months of life. Butte
Aug-11
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Aug-11
Nutrients of concern - amounts in breastmilk depend on
In populations with
deficiency of these
Vitamin D
Vitamin K
Vitamin A
Vitamin B6
Vitamin C
Iodine
In Vegans
Vitamin B12
Aug-11
26
Vary with maternal diet

Vitamin A
Thiamin
Riboflavin
B6, B12
Vitamin C
Iodine, Selenium
(Fat)
28
Deficient populations
mothers nutritional status and may not be enough for young

baby
In adequately nourished
populations.
Independent of
maternal diet
Protein
Iron
Zinc
Calcium
Folic Acid
Copper
Mean intakes human milk provide sufficient energy,

protein, calcium to meet requirements during first 6
months of life.
Vit A and B6 OK in well nourished populations. In
deficient populations, supplements required.
Vitamin D depends on sunlight exposure
Iron and Zinc needs are met from foetal stores
Suggestions
Baby needs some exposure to sunshine
If this not feasible:
High dose supplement to mother, can elevate
breastmilk content and lead to normal infant status
Or Supplement baby with Vitamin D drops
Influence of maternal diet on breastmilk

micronutrient content
et al. WHO 2002
Aug-11
EXBF? These babies at risk because infants stores at

birth probably low.
Questions:
Did mother have vitamin D supplements?
Thiamin (B1)
Beri-beri occurs in
breastfed infants of
deficient mothers.
Food sources: animal
foods, whole grains &
legumes
Occurs when diet =
mainly polished rice
B6 - rare
Low vit B6 status in
breastfed infants of
mothers with low Vit
B6.
Leads to compromised
growth, reversible
through appropriate
complementary
feeding.
Sources meat, fish,
potatoes, bananas, pulses

Penh, Cambodia
29
Aug-11
30
Carol Williams
Maternal nutrition influences breastmilk

through 3 mechanisms:
Mothers Nutrition & Breastfeeding
A poor diet is NEVER a reason for a mother

not breastfeed her child
Current dietary intake

Nutrient stores
Alterations in nutrients utilisation/absorption
under the influence of the hormones
associated with breastfeeding
Generally, only when deprivation is extreme do
supplements improve breastmilk content, but
may benefit mother.
Aug-11

Penh, Cambodia
The composition of breastmilk is

remarkably robust
A mothers body stores are used to make
the breastmilk if her diet is poor
It is always better to give the mother more
food, than to supplement the child.
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Aug-11
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Carol Williams

IFCcic & World Vision

Infant Feeding Consortium cic.

Iodine deficiency during pregnancy