You are on page 1of 14

Clinical Expert Series

Continuing medical education is available online at

Optimal Nutrition for Improved Twin

Pregnancy Outcome
William Goodnight, MD, MSCR, and Roger Newman, MD, for the Society of Maternal–Fetal Medicine

Twin pregnancies contribute a disproportionate degree to perinatal morbidity, partly because of

increased risks of low birth weight and prematurity. Although the cause of the morbidity is
multifactorial, attention to twin-specific maternal nutrition may be beneficial in achieving optimal
fetal growth and birth weight. Achievement of body mass index (BMI)-specific weight gain goals,
micronutrient and macronutrient supplementation specific to the physiology of twin gestations, and
carbohydrate-controlled diets are recommended for optimal twin growth and pregnancy outcomes.
The daily recommended caloric intake for normal-BMI women with twins is 40 – 45 kcal/kg each day,
and iron, folate, calcium, magnesium, and zinc supplementation is recommended beyond a usual
prenatal vitamin. Daily supplementation of docosahexaenoic acid and vitamin D should also be
considered. Multiple gestation-specific prenatal care settings with a focus on nutritional interventions
improve birth weight and length of gestation and should be considered for the care of women
carrying multiples. Antepartum lactation consultation can also improve the rate of postpartum
breastfeeding in twin pregnancies. Twin gestation-specific nutritional interventions seem effective in
improving the outcome of these pregnancies and should be emphasized in the antepartum care of
multiple gestations. This review examines the available evidence and offers recommendations for
twin pregnancy-specific nutritional interventions.
(Obstet Gynecol 2009;114:1121–34)

T he increasing rate of twin gestations is well docu-

mented. Twin gestations account for a dispropor-
tionate share of neonatal morbidity, with increased
risks of preterm birth, low birth weight, and intrauter-
ine growth restriction. Infants of multiple births rep-
resent 3% of all deliveries but account for 15% of
preterm birth, 20% low birth weight (LBW; less than
From the Departments of Obstetrics and Gynecology, Division of Maternal–Fetal
2,500 g), and 19 –24% of very low birth weight (less
Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North than 1,500 g) neonates born in the United States.
Carolina; and Medical University of South Carolina, Charleston, South Carolina. Optimal twin survival has been demonstrated to be
The practice of medicine continues to evolve and individual circumstances will associated with birth weights more than 2,850 g and
vary. This opinion reflects information available at the time of its acceptance for
publication, and is neither designed nor intended to establish an exclusive delivery after 36 weeks gestational age.1–3 Unfortu-
standard of care. This publication is not expected to reflect the opinions of all nately, twins often deliver with average birth weights
members of the Society for Maternal–Fetal Medicine.
between 2,300 g and 2,600 g at a mean gestational age
Continuing medical education for this article is available at http://links.lww. of 35 weeks to 36 weeks. Impaired fetal growth is also
associated with long-term complications, including an
Corresponding author: William Goodnight, MD, MSCR, Department of
Obstetrics and Gynecology, Division of Maternal–Fetal Medicine, University of increased lifetime risk of cardiovascular disease and
North Carolina at Chapel Hill, 3010 Old Clinic Building/CB# 7516; Chapel obesity. Neonatal body composition in appropriately
Hill, NC 27599-7516; e-mail:
grown twin gestations is similar to singleton neonates,
Financial Disclosure
whereas small for gestational age twins have a lower
The authors did not report any potential conflicts of interest.
lean body mass, a lower fat mass, and a trend to lower
© 2009 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins. bone density compared with small for gestational age
ISSN: 0029-7844/09 singleton neonates.4


Maternal pregestational and gestational nutri- energy expenditure increases each trimester in both
tional status in singleton pregnancies without question singleton and multiple gestations.9 Singagawa et al9
is associated with pregnancy outcome. The nutritional demonstrated that compared with singleton pregnan-
demands of pregnancy are magnified by the presence cies, maternal resting energy expenditure increased
of multiple fetuses, and the potential beneficial impact by 10% in twin pregnancies, independent of changes in
of optimal nutrition on pregnancy outcomes should minute ventilation. The increase in resting energy ex-
not be underestimated. Thus, the nutritional recom- penditure can also be seen as a result of the increased
mendations for singleton pregnancy require specific mass of maternal tissues, including the breast, uterus,
adaptation for a multifetal gestation. The nutritional body fat, and muscle as well as the increase in blood
competition engendered by the presence of multiple volume. Such an increase in resting energy expenditure
fetuses results in the accelerated depletion of maternal can result in a 40% increase in caloric requirements for
nutritional reserves.5 Although monochorionic twin twin gestations.
pregnancies carry a greater risk of the above adverse The relatively larger placental mass in multiple
pregnancy outcomes than dichorionic twins, there are gestations results in an increase in placental steroid
similar rates of selective intrauterine growth restric- and hormone production.7 As a result, multifetal
tion between monochorionic and dichorionic twins.6 gestation has been described as a state of “accelerated
The overall risk of fetal growth restriction in twin starvation,” in which the development of starvation
pregnancies creates a situation where modification of ketosis occurs at a more rapid rate in twin gestations
nutritional intake has a greater opportunity to posi- than in a singleton pregnancy. These hormonally
tively influence the outcome for twins compared with driven metabolic changes result in remarkable mater-
singleton gestations. This article will suggest specific nal carbohydrate use, resulting in a greater propensity
maternal nutritional recommendations for twin preg- for depletion of maternal hepatic glycogen stores and
nancy based on available scientific evidence. the development of maternal ketonemia. Casele et
The goals for optimization of maternal nutrition al10 demonstrated that women with twin gestations fed
in multiple gestations therefore include a diet of 40 kcal/kg ideal body weight, divided into
three meals, are more susceptible to the development
1. optimizing fetal growth and development,
of ketosis after fasting, as evidenced by elevated
2. reducing incidence of obstetric complications,
␤-hydroxybutyrate serum levels after an evening fast
3. increasing gestational age at delivery, and
compared with singleton gestations. Classically, the
4. avoiding excess maternal weight gain that could
United States Department of Agriculture (USDA),
result in unnecessary postpartum weight retention. Institute of Medicine (IOM), and American Dietetic
Association (ADA) recommendations for reproduc-
PHYSIOLOGIC ADAPTATIONS TO TWIN tive age women suggest that 45– 65% of calories daily
PREGNANCY be derived from carbohydrates,11 a diet that has been
Multifetal gestations undergo significant maternal suggested to result in poor glycemic control and
physiologic adaptations beyond the usual pregnancy excess weight gain in twin gestations.12 Luke et al12
changes, including increased plasma volume, in- demonstrated that a diet composed of 40% carbohy-
creased basal metabolic rate, and increased resistance drates and a greater percentage of fats and protein
to carbohydrate metabolism. The blood volume in a with an appropriate caloric intake (3,000 – 4,000
twin gestation increases by 50 –70% by 20 weeks of kcal/d in underweight to normal weight women)
gestation, with only a 25% increase in erythrocytes.7 achieved a greater degree of euglycemia during preg-
This plasma volume expansion results in decreased nancy. Other limited trials also suggest that a lower
concentrations of hemoglobin, albumin, and water- proportion of carbohydrates in the diet in women with
soluble vitamins, whereas increases in fat-soluble vi- gestational diabetes is associated with improved glyce-
tamins, triglycerides, cholesterol, and free fatty acids mic control, as evidenced by lower insulin utilization.
have been demonstrated.7 The relatively greater in-
crease in plasma volume in a twin pregnancy also DIETARY COMPOSITION
results in a dilutional effect on red blood cells in the Although no established nutritional guidelines exist,
second and third trimesters of pregnancy.8 an estimate of individual macronutrient requirements
The resting energy expenditure is an indicator of for twins is described in Table 1. These recommen-
maternal basal metabolic rate that can be used to dations are based on extrapolation of the singleton
estimate energy requirements. The maternal resting recommended dietary allowances (RDA) published

1122 Goodnight and Newman Twin Nutrition OBSTETRICS & GYNECOLOGY

Table 1. Suggested Daily Diet Composition for Twin Gestation by Maternal Prepregnancy Body Mass
Underweight Normal Weight Overweight Obese
Calories (kcal) 4,000 3,000–3,500 3,250 2,700–3,000
Protein (g)* 200 175 163 150
Carbohydrate (g)* 400 350 325 300
Fat (g)† 178 156 144 133
* 4 kcal/g.

9 kcal/g.

by the Food and Nutrition Board of the National deral index (increased carbohydrates resulted in neo-
Research Council and body mass index (BMI)-spe- natal thinness).13 Ideal protein sources include lean
cific recommendations for twin gestations published meat, fish, and skin-free poultry, eggs, dried beans,
by Luke and coworkers. Luke et al12 have proposed a peas, and tofu. An emphasis on low to medium
dietary composition for twins in which energy intake glycemic index carbohydrates (such as brown rice,
is derived 20% from protein, 40% from low-glycemic whole wheat/multigrain bakery products and pastas,
index carbohydrates, and 40% from fat (Table 1). Due boiled potatoes, green vegetables, beans, and lentils)
to the increased nutritional demands of the fetus and is also suggested to further reduce the potential for
maternal metabolism, these recommendations equate wide serum glucose fluctuations. To gain the neces-
to a daily intake of 3,500 calories, composed of a diet sary calories, the proportion of caloric rich fats is
with 175 g protein, 350 g of carbohydrate, and 156 g substituted for carbohydrates.14 Table 2 suggests the
of fat per day for women of normal prepregnancy number of serving suggestions daily to achieve this
BMI. Adequate protein intake is essential to normal diet composition and caloric requirements.14 This
fetal growth in twin gestations. In singleton pregnan- dietary intake should be divided into three main
cies, the protein storage during pregnancy has been meals with three smaller snacks interposed in the
estimated to be 925 g, distributed as 400 g to the fetus, usual meal schedule to help reduce the development
100 g to the placenta, and 425 g additional stored in of hypoglycemia and transient ketosis.14 In under-
the mother.7 Inadequate protein intake can occur weight women (BMI less than 19.8 kg/m2) and those
secondary to insufficient dietary intake, intake of poor with poor weight gain in pregnancy, addition of
quality protein (high fat meats), or inadequate caloric higher fat, calorie-rich foods, including nutritional
intake, which results in dietary protein being diverted supplement drinks, whole or 2% milk, fruit juices, and
to meet maternal energy requirements.12 Reduced the change to five balanced meals per day can achieve
amino acid availability to the fetus not only affects fetal the necessary weight gain. Similarly, excessive weight
growth but may also restrict placental growth, further gain in pregnancy should lead to a reduction in these
compounding the effect of protein deficiency.12 Addi- high fat, calorie-dense foods.
tionally, Moore et al13 evaluated maternal diet compo-
sition and the effect on neonatal weight and ponderal WEIGHT GAIN
index. The percentage of energy from protein (14.4 – Total maternal weight gain and the timing of weight
18.1% in this study) in early pregnancy had the best gain are crucial to optimal fetal growth in twin
positive association with neonatal weight, whereas the gestations. The preponderance of the evidence in
percentage of energy from carbohydrates (45.3–53.2% singleton gestations is that there is a relationship
in this sample) was inversely proportional to the pon- between increasing maternal weight gain and in-

Table 2. 2002 American Dietetic Association Serving Suggestions for Multiple Pregnancy of Normal Body
Mass Index
Milk/Yogurt/ Meat/Poultry/ Bread/Cereal/
Cheese Fish/Eggs Vegetable Fruit Rice/Pasta
Daily 3 3 3 2 6
Serving 1 cup milk; 1 2–3 oz lean meat, 1 cup raw/cooked 1 cup fruit; cup 1 slice bread; 1 cup ready
suggestion oz cheese fish, poultry; vegetables; 2 cups raw dried fruit to eat cereal; cup
1 egg green leafy vegetables cooked rice/pasta

VOL. 114, NO. 5, NOVEMBER 2009 Goodnight and Newman Twin Nutrition 1123
creases in birth weight, with a corresponding reduc- newborn birth weights determined to be between the
tion in the incidence of low birth weight. The pub- singleton 50th and twin 90th percentiles by 38 weeks
lished literature also suggests that low maternal of gestation. Among twins achieving these optimal
weight gain superimposed on a low maternal pre- fetal growth and birth weights, the associated mater-
gravid weight compounds the adverse affects of each, nal BMI-specific weight gains were found to be
resulting in high rates of both low birth weight described by the maternal weight gain curves noted in
delivery and premature birth. The effect of low Figure 1.21 In a follow-up study of the effects of using
maternal weight gain is diminished in women with these BMI-specific weight gain recommendations,
higher pregravid weights. Historically, weight gain twin gestations that failed to achieve BMI-specific
recommendations were made to reduce the risk of weight gain goals demonstrated a lower birth weight
LBW, with contemporary recommendations made to by nearly 200 g (P⬍.001) and a 1.04-week shorter
achieve optimal fetal growth without excess maternal length of gestation (P⫽.02) (Goodnight W, Hill E,
weight gain. Early retrospective studies attempted to Newman R, Rowland A. Achieving maternal BMI-
define the appropriate maternal weight gain for twin specific weight gain goals improves birthweight and
gestations based on optimal neonatal outcomes. Ped- gestational age at delivery in twin pregnancies [ab-
erson et al15 demonstrated that optimal twin preg- stract]. Am J Obstet Gynecol 2006;195:S121). Based
nancy outcome, defined as two living infants, each in part on this new data, the 2009 IOM guidelines for
more than 2,500 g, born after 37 weeks estimated weight gain in twin pregnancy now recommend BMI-
gestational age, and 5-minute Apgar score more than specific weight gains for normal weight women of
7 was associated with a maternal weight gain of 20 kg 17–25 kg (37–54 lb), overweight women, 14 –23 kg
(44 lb). Less than optimal outcomes were seen with (31–50 lb), and obese women, 11–19 kg (25– 42 lb).22
maternal weight gains less than 16.8 kg (37 lb).15 The The small differences from Luke et al are based on
timing and the rate of maternal weight gain also affect different BMI categories used in the IOM recommen-
both birth weight and prematurity. Midgestational dations. In practice, we continue to use the graphs
maternal weight gains seem to have the greatest effect created by Luke et al to track and recommend
on fetal growth and ultimate birth weight.16,17 Optimal maternal weight gain during pregnancy.
twin outcomes (birth weight more than 2,500 g) have Determinants of maternal weight gain in preg-
been associated with maternal weight gain of 24 lb by nancy have not been extensively studied in multiple
24 weeks of gestation.16,18 Even when there is appro- gestations but are likely influenced by multiple bio-
priate catch-up maternal weight gain after 24 weeks, a logic, behavioral, cultural, and psychosocial factors.
low rate of weight gain before 24 weeks (less than 0.85 Wells et al23 demonstrated in a retrospective analysis
lb/wk) was strongly associated with poor intrauterine that maternal obesity and hypertension are associated
growth and earlier delivery.16,18,19 In studies making with a greater risk for weight gain above the IOM
use of serial ultrasonographic measures of fetal recommended weight gains, whereas diabetes was not
growth in relation to maternal weight gain, it has been associated with excessive or below IOM weight gain
demonstrated that early maternal weight gain (less goals, and prior live births was associated with lower
than 20 weeks) and midpregnancy weight gain (20 –28 risk of excessive maternal weight gain in pregnancy.
weeks) significantly enhanced the rates of fetal growth Initial physician counseling is thus necessary to deter-
between 20 weeks and 28 weeks and from 28 weeks mine maternal perceptions of weight gain goals, re-
until birth.20 As noted in singleton gestations, this view potential maternal risk factors for excessive or
influence of early maternal weight gain on subsequent poor weight gain, and provide education and support
fetal growth was most pronounced in underweight to achieve optimal weight gain goals.
women. Physiologically, this relationship suggests that Although it is well established that increased mater-
early weight gain results in improved maternal nutrient nal weight gain in pregnancy increases birth weight in
stores that become important later in pregnancy as a twins, the long-term effects of retained maternal weight
nutrient reserve when fetal demands begin to increase. after delivery remains of concern. Although not exten-
Adequate early maternal weight gain may also enhance sively evaluated in multiple gestations, excessive mater-
placental growth, which helps to sustain an adequate nal weight gain in pregnancy may be associated with
nutrient supply to the twins later in pregnancy. increased risks of gestational hypertension, cesarean
Luke et al21 suggested weight gain goals for twin delivery, and birthweight more than 4,000 g (rare in
pregnancy based on maternal prepregnancy BMI. twins).24 The weight gain recommendations for twin
Optimal maternal weight gain and timing of weight pregnancy have been criticized for potentially contrib-
gain were modeled based on ideal fetal growth and uting to the risk of maternal obesity through postpartum

1124 Goodnight and Newman Twin Nutrition OBSTETRICS & GYNECOLOGY

30 28.1 (62 lb)
25 22.2 (49 lb)
25 24.5 (54 lb)
Weight gain (kilograms)

Weight gain (kilograms)

20 20.0 (44 lb)
22.7 (50 lb)
15.9 (35 lb)
15 13.6 (30 lb) 18.1 (40 lb)
16.8 (37 lb) 15

10 10 13.6 (30 lb)

11.3 (25 lb)
9.1 (20 lb)
5 5

0 20 28 38
20 28 38
Gestational age (weeks)
A Gestational age (weeks) B

Weight gain (kilograms)

21.3 (47 lb)

Weight gain (kilograms)

20 20
16.8 (37 lb) 17.2 (38 lb)
15 15 13.6 (30 lb)
17.2 (38 lb)
11.3 (25 lb)
12.7 (28 lb) 9.1 (20 lb) 13.2 (29 lb)
10 10
9.5 (21 lb)
9.1 (20 lb)
5 5 6.8 (15 lb)

0 0
20 28 38 20 28 38
C Gestational age (weeks) D Gestational age (weeks)

Fig. 1. Body mass index-specific weight gain goals. A. Maternal weight gain in kilograms for underweight prepregnancy
body mass index (BMI) (BMI less than 19.8 kg/m2). B. Maternal weight gain in kilograms for normal prepregnancy BMI (BMI
19.8 –26 kg/m2). C. Maternal weight gain in kilograms for overweight prepregnancy BMI (BMI 26.1–29 kg/m2). D. Maternal
weight gain in kilograms for obese prepregnancy BMI (BMI more than 29 kg/m2). Modified from Luke B, Hediger ML, Nugent
C, Newman RB, Mauldin JG, Witter FR, et al. Body mass index-specific weight gains associated with optimal birth weights
in twin pregnancies. J Reprod Med 2003;48:217–24.
Goodnight. Twin Nutrition. Obstet Gynecol 2009.

retention of the weight gain. Luke et al (Luke B, Hediger assessment of weight gain and equal intervention to
ML, Min L, Nugent C, Newman RB, Hankins GD, et al. prevent or slow excessive weight gain.
The effect of weight gain by 20 weeks’ gestation on twin
birthweight and maternal postpartum weight [abstract]. MICRONUTRIENTS
Am J Obstet Gynecol 2006;195:S85), however, demon- Recommendations for micronutrient intake are deter-
strated that the mean weight retention for those who mined by the Food and Nutrition Board of the
gained within the recommended BMI specific weight Institute of Medicine. Dietary Reference Intakes have
gain goals was only 1.5 lb at 6 weeks postpartum, replaced the RDA estimates. The RDA recommen-
minimally above the 0.9 lb weight retention seen in dations were determined to estimate the intake
those with maternal weight gain below the BMI-specific needed to meet the needs of 97–98% of the popula-
weight gain goals. In singleton pregnancy, long-term tion, whereas an Adequate Intake is estimated to
maternal weight (15 years postpartum) was equivalent cover the needs for all individuals in a specific group.
among women who gained below or within IOM These estimates are supplemented by the Tolerable
recommendations, with excessive maternal weight gain Upper Intake Levels, an estimate of the maximal
in pregnancy associated with higher long-term weight intake level that should not cause harm. Nutrients
gain.25 Thus, in the multiple gestation clinical situation, such as magnesium, calcium, and zinc are often
attention should be given to both achievement of the lacking in women’s diets and may have effects on fetal
recommended maternal weight gain goals and serial growth and preterm delivery. In a randomized, pla-

VOL. 114, NO. 5, NOVEMBER 2009 Goodnight and Newman Twin Nutrition 1125
cebo controlled clinical trial in 2004, Hininger et al26 calcium being absorbed. The IOM recommends a
demonstrated that micronutrient supplementation (vi- calcium intake in pregnancy of 1,000 –1,300 mg daily
tamin C 60 mg, B-carotene 4.8 mg, vitamin E 10 mg, (Tolerable Upper Intake Levels 2,500 mg). A Co-
thiamin 1.4 mg, riboflavin 1.6 mg, niacin 15 mg, chrane review of calcium supplementation of at least
pantothenic acid 6 mg, folic acid 200 microgram, 1,000 mg daily in pregnancy, not specifically describ-
cobalamin 1 microgram, zinc 15 mg, magnesium 87.5 ing twin gestations, demonstrated significant reduc-
mg, and calcium carbonate 100 mg) in pregnancy tions in the risks of hypertension (relative risk [RR]
resulted in a 10% improvement in birth weight 0.7, 95% confidence interval [CI] 0.57– 0.86) and
(3,300⫾474 g compared with 3,049⫾460 g, P⫽.03) preeclampsia (RR 0.48, 95% CI 0.33– 0.69) in both
and a reduction in birth weight below 2,700 g among low- and high-risk populations.29 The effects of cal-
singleton pregnancies. There are fewer data available cium supplementation were most beneficial in high-
on micronutrient supplementation in twin pregnan- risk women and in those with low dietary calcium
cies. However, the expectation would be that similar intake.30 These findings are likely applicable to twin
or greater benefits may be expected because micro- pregnancies because of the increased fetal demands
nutrient needs are greater and deficiencies may be for calcium and the increased baseline risk of pre-
more common in multiple gestations. Because twin eclampsia in these gestations. Calcium supplementa-
gestations are at increased risk for poor fetal growth tion may also have fetal programming effects that
and preterm birth, small improvements from benign persist into childhood. In a trial by Belizan et al,31
interventions such as micronutrient supplementation children of mothers who received calcium supple-
may have significant benefits. ment in pregnancy had lower rates of hypertension
Although the majority of micronutrient supple- (RR 0.59, 95% CI 0.39 – 0.9). The presence of mater-
ments have a wide safety margin, notable potentially nal contraindications to calcium supplementation (eg,
adverse complications may arise from excessive mi- nephrolithiasis) may require reductions in the daily
cronutrient supplementation. Excessive doses of vita- supplement.
min A (at least more than 10,000 international units/d Vitamin D is also necessary for the appropriate
and probably more than 25,000 international units/d) metabolism of calcium, and deficiency is common in
in pregnancy have been associated with fetal anoma- pregnancy.32 Fetal vitamin D is dependent on mater-
lies, including anomalies of the cardiovascular system, nal vitamin D levels, and low maternal vitamin D is
face and palate, ears, and genitourinary tract; thus, the the dominant risk factor for neonatal rickets. The
maximal recommended vitamin A supplement in active metabolite of vitamin D is 1,25-dihydroxyvita-
pregnancy is 8,000 international units/d. Excessive min D [1,25 (OH)2D], which facilitates intestinal
supplementation of most other vitamins can result in calcium absorption and calcium mobilization from
gastrointestinal disturbances but seem without terato- bone, and decreases renal calcium excretion.33 The
genic effect. serum concentration of 1,25 (OH)2D increases 50 –
75% in the second trimester (mean 176⫾36 pmol/L)
CALCIUM AND VITAMIN D and doubles by the third trimester (mean 212⫾83
During in utero life, the fetus accumulates 25–30 g of pmol/L), compared with the nonpregnant state
calcium, the majority of which occurs in the third (100⫾32 pmol/L).28,33 The current Dietary Reference
trimester.27 Calcium is made available to the fetus by Intake recommendation for vitamin D is 400 interna-
extraction from maternal bone mass and through tional units/d based on estimated adequate intakes;
increased maternal intestinal absorption.27 Maternal however, supplementation at this dose in adults does
calcium is also lost in pregnancy because of an not result in increased circulating 25(OH)D levels.34
increase in urinary calcium excretion.28 An estimated Adults require sun exposure daily for conversion of
200 –300 mg/d increase in calcium intake above vitamin D to 1,25 (OH)2D, with whites requiring 0.5
prepregnancy requirements is thus required to meet hours per day and African Americans requiring 5
the fetal demands and maintain maternal calcium times this amount.34 For those with minimal sun
homeostasis.28 During lactation, there is a reduction in exposure, supplementation during pregnancy should
urinary calcium excretion.28 However, the majority of approach 1,000 international units/d. Wagner and
pregnant women do not consume diets with an ade- Greer35 report that vitamin D supplementation of
quate calcium intake. Food sources for calcium are levels more than 1,000 international units/d are nec-
primarily milk and dairy products, with some calcium essary to achieve normal vitamin D levels (more than
in green leafy vegetables such as kale and turnip 50 nmol/L 25-OH-D). This supplement, plus appro-
greens, with approximately one third of ingested priate sun exposure, will not result in high levels

1126 Goodnight and Newman Twin Nutrition OBSTETRICS & GYNECOLOGY

associated with hypervitaminosis D (hypercalciuria, grams/d vitamin C/vitamin E reasonable for twin
hypercalcemia, and extraskeletal calcifications with gestations, whereas specific trials in twin pregnancy
symptoms of nausea and vomiting and arthralgias), await. Vitamin C and E have not been associated with
but will provide adequate vitamin D levels for mater- toxicities at very high doses, with the exception of
nal and fetal development.34 Vitamin D supplemen- gastrointestinal disturbances, and no adverse fetal
tation during pregnancy has been associated with an effects have been noted. Vegetable oils are the pri-
increase in birth weight as well as an increase in mary source of vitamin E, whereas vitamin C is found
newborn weight gain,34 whereas deficiency has been in citrus fruit and green vegetables.
associated with an increased risk of preeclampsia.36
Thus, vitamin D supplementation may be beneficial ZINC AND MAGNESIUM
in twin gestations. The Dietary Reference Intakes/ Zinc is necessary in several biologic systems, includ-
Tolerable Upper Intake Levels for calcium and Vita- ing protein synthesis and nucleic acid metabolism as
min D are 1,300 mg/2,500 mg and 200 international well as prevention of free radical formation. Meats,
units/2,000 international units daily, thus the diet seafood, and eggs provide the optimal dietary sources
recommendation for twin gestations includes 2,000 – of zinc. Zinc deficiency, although rare, may be asso-
2,500 mg/d of calcium and 1,000 international units ciated with fetal neurologic malformations and
of vitamin D daily. Due to the variations in sun growth restriction, and late pregnancy deficiency may
exposure and vitamin D levels, assessment of mater- also be associated with impaired brain function and
nal vitamin D levels in twins should be considered in behavior abnormalities due to abnormal neuronal
first and early third trimester to allow alterations in growth.42 Zinc supplementation in pregnancy may
the supplement dosage. Attention to vitamin D sup- improve several pregnancy outcomes, including re-
plement is especially important given the frequent ducing preeclampsia and preterm birth, and result in
occurrence of complications resulting in bedrest in improved birth weight in deficient populations. Hin-
twin pregnancy. niger et al26 demonstrated that maternal zinc levels
were not different between supplemented or placebo
ANTIOXIDANTS, VITAMIN C AND E groups in a multinutrient supplement trial, but zinc
The role of antioxidant supplements to reduce the risk levels did correlate well with neonatal length (r 0.58,
of preeclampsia and preterm birth has been investi- P⫽.03). Although there are few data in twin gesta-
gated in pregnancy. Early studies demonstrated a tions, a systematic review of zinc supplementation of
reduction in the recurrence of preeclampsia and an 15– 44 mg daily in pregnancy was associated with a
improvement in the plasminogen-activator inhibitor 14% reduction in preterm birth (RR 0.86, 95% CI
PAI-1 to PAI-2 ratio (favorable antioxidant measure) 0.76 – 0.98), with the majority of the effect seen in
with vitamin C (1,000 mg) and vitamin E (400 micro- nutritionally deficient populations.43 However, no ef-
grams) supplementation during pregnancy.37,38 The fect on birth weight was seen. Although zinc metab-
VIP trial,39 however, did not reveal any reduction in olism has not been systematically studied in multiple
preeclampsia either in the overall at-risk population gestations, zinc supplementation could theoretically
or in a subgroup of twin gestations. Nevertheless, be beneficial in this population at high risk for
analysis of serum vitamin C levels was noted to be preterm birth and LBW. The Dietary Reference
lower in the supplemented group who developed Intakes/Tolerable Upper Intake Levels for zinc is 12
preeclampsia compared with those who did not re- mg/40 mg/d respectively.41 Zinc is not stored in the
ceive supplementation. The VIP trial, however, dem- body and virtually nontoxic; rare cases of leukopenia
onstrated an increased risk of LBW in those with and anemia have been reported with prolonged in-
vitamin C and E supplementation (RR 1.15, 95% CI take of more than 50 –300 mg/d. Based on National
1.02–1.30, P⫽.02). Vitamin C has also been suggested Health and Nutrition Examination Survey III data,44
to provide protection against preterm premature rup- 59% of pregnant women achieve adequate intake
ture of membranes in singleton pregnancy.40 Antiox- (supplement and diet) of zinc, with a mean dietary
idant trials to date have examined primarily singleton intake of 9.2 (⫾2.1) mg. Thus achievement of daily
gestations and demonstrate the most significant ben- intake of zinc of 14 – 45 mg/d is recommended for
efit in pregnancies with nutritional deficiencies. The twin gestations, often requiring supplement.
current Dietary Reference Intakes/Tolerable Upper Although individual trials of variable quality and
Intake Levels for vitamin C and E, respectively, are design demonstrate conflicting results regarding the
80/1,800 mg/d and 15/800 micrograms/d,41 making effects of magnesium supplementation on preterm
suggested intakes of 500 –1,000 mg/400 micro- birth and fetal growth, a systematic review by

VOL. 114, NO. 5, NOVEMBER 2009 Goodnight and Newman Twin Nutrition 1127
Makrides and Crowther45 in singleton pregnancies daily replacement with 60 –120 mg of elemental iron
demonstrated a reduction in preterm birth more than will increase the hemoglobin concentration by 1g/dL
37 weeks (RR 0.73, 95% CI 0.57– 0.94) and LBW (RR over 4 weeks.
0.67, 95% CI 0.46 – 0.96). The authors of this analysis The ideal source of iron supplementation is from
summarized that no conclusions about the beneficial an adequate diet that includes heme iron–rich food
effects of magnesium supplementation on pregnancy sources such as red meat, pork, fish, and eggs. These
outcome could be made due to the poor quality of the sources of dietary iron are ideal in that they not only
included trials, and twin data remain lacking. The provide iron that is more easily absorbed but also
Dietary Reference Intake for magnesium in pregnancy represent a higher quality and quantity of protein.
is 350 – 460 mg/d and supplementation of up to 1,000 Nonheme iron sources, such as iron fortified bread,
mg daily has been suggested for twin gestations.14 leafy green vegetables, and nuts, should also be
encouraged both for their iron content as well as for
ANEMIA AND IRON REQUIREMENTS the presence of folate. The Dietary Reference Intake/
Iron deficiency is the most common nutritional defi- Tolerable Upper Intake Levels for iron are 27 mg/45
ciency worldwide, and has been associated with pre- mg daily, respectively.41 Supplementation of nonane-
term birth and low birth weight. In the United States, mic twin gestations of 30 mg daily of elemental iron
estimates of iron deficiency anemia in pregnancy would be appropriate to meet the increased maternal
range from 5–17%, whereas estimates of low maternal and fetal needs of the pregnancy.
ferritin (less than 15 micrograms/L) with normal Folic acid is also an important micronutrient in
hemoglobin are seen in up to 20% of pregnant pregnancy because it is essential in DNA synthesis
women. Fetal and neonatal iron deficiency, as mea- and cell division. Folate is required for the increase in
sured by cord blood ferritin level less than 30 micro- maternal red blood cells as well as for the growth of
grams/L is associated with severe maternal anemia the fetus. Hyperhomocysteinemia is associated with
(hemoglobin less than 6.0 g/dL).46 Both mild maternal deficiency in folate and has been associated with
anemia (hemoglobin less than 8.5 g/dL) and a mater- intrauterine growth restriction, preeclampsia, and pla-
nal ferritin level less than 12 micrograms/L are asso- cental abruption through vascular endothelial injury.
ciated with poor fetal iron supply.46 Scholl et al47 Anemia due to folate deficiency is eight times more
demonstrated an association between iron deficiency common in twins than in singleton pregnancy.7 Trials
and poor maternal weight gain (adjusted odds ratio of folic acid supplement in pregnancy have not dem-
[AOR] 2.67, 95% CI 1.13– 6.3). Additionally, iron onstrated consistent improvements in pregnancy out-
deficiency anemia was also associated with an in- come, with one meta-analysis demonstrating a reduc-
creased risk of preterm birth (AOR 2.66, 95% CI tion in the risk of low birthweight (RR 0.73, 95% CI
1.15– 6.17) and LBW (AOR 3.10, 95% CI 1.16 – 0.53– 0.99)50 and a retrospective review demonstrat-
4.39).47 Cogswell et al48 demonstrated that iron sup- ing a reduction in the risk of preterm birth with
plementation with 30 mg elemental iron daily re- preconception folic acid supplementation.51 The cur-
sulted in a significant increase in birth weight (200 g) rent recommendation for folic acid in the preconcep-
compared with placebo even in the presence of tion period and during pregnancy include 400 micro-
normal serum ferritin levels in the first trimester. grams/d, whereas the Dietary Reference Intake/
Twin pregnancies have lower maternal hemoglo- Tolerable Upper Intake Levels for folate are 600
bin levels in the first and second trimesters and higher micrograms/1,000 micrograms daily.41 Based on
rates of iron deficiency anemia, and the resulting these recommendations, 1mg daily folic acid is sug-
infants have increased risk of residual iron deficiency gested for twin gestations.
anemia for up to 6 months of age. The rate of iron
deficiency anemia is 2.4 – 4 times higher than in OMEGA-3-FATTY ACIDS
singleton pregnancies. The iron requirement for twin Essential fatty acids (EFA) are lipids that cannot be
pregnancy is estimated to be nearly twofold that of a synthesized in the body and thus require appropriate
singleton pregnancy.7 Rosello-Soberon et al7 reported dietary intake. Essential fatty acids are involved in
an estimated 869 mg elemental iron requirement for many metabolic processes, including energy storage,
twins compared with 476 mg for singleton pregnan- cell membrane function (including neuronal develop-
cies. Iron supplementation during the first and second ment), control of inflammation, and control of throm-
trimesters has been associated with reductions in both bosis.52 Two groups of EFA exist: omega-6 (␻-6FA:
preterm birth and LBW.49 In women with iron defi- linoleic acid, derived from cereals, grains, processed
ciency (serum ferritin less than 15 micrograms/L), foods, meat, milk, eggs, and oils, including corn,

1128 Goodnight and Newman Twin Nutrition OBSTETRICS & GYNECOLOGY

sunflower, safflower, and sesame) and omega-3 (␻- rable to fish consumed in the United States (0.05– 0.25
3FA: ␣-linolenic acid, only found in selected seeds, ppm methylmercury) on a daily basis, have not
nuts, and fish oils).52 Because plant sources may not demonstrated adverse neurodevelopmental delay in
contain the necessary docosahexaenoic acid (DHA) the offspring to 66 months of life.58 Maternal con-
component of ␻-3FA, the optimal nutritional source is sumption of seafood in a large epidemiologic study in
fish oils. Optimal homeostatic inflammatory and England demonstrated that low maternal consump-
thrombotic states have been theorized to result from a tion (less than 340 g/wk) was associated with an
balance between ␻-3FA and ␻-6FA, with ideal diets increased risk of their children being in the lowest
having a ratio of ␻-6 to ␻-3 of 1–2:1.52 A deficiency in quartile for verbal IQ, as well as more common
␻-3 results in a prothrombotic and proinflammatory suboptimal social behaviors, fine motor and commu-
state that has been associated with an increased risk of nication skills, and social development scores,59 sug-
cardiovascular and inflammatory diseases.52 A typical
gesting low ␻-3FA exposure being associated with an
Western diet currently has an ␻-6 to ␻-3 ratio of
increased risk of adverse neurologic development.
The World Health Organization currently recom-
In comparison with singleton pregnancies, neo-
mends 300 –500 mg per day of ␻-3FA (such as DHA
nates born of twin pregnancies have lower levels of
␻-3FA in the walls of their umbilical veins and and eicosapentaenoic acid) in an effort to promote
arteries, indicating an inadequate dietary supply.53 An fetal and early childhood mental development. Con-
in vitro trial of singleton and twin pregnancies dem- sumption of at least two meals (12 oz total) weekly of
onstrated that DHA concentration in fetal erythrocyte low-mercury– containing fish (eg, shrimp, canned
membrane was directly related to maternal concen- light tuna, salmon, pollock, and catfish) by pregnant
tration and that lower concentration of ␻-3FA was women, those planning pregnancy, or breastfeeding
associated with increased membrane rigidity and in- women, contributes to an adequate ␻-3FA intake for
creased resistance to flow.54 In this study, the mean optimal fetal neurodevelopmental and obstetric out-
erythrocyte DHA concentration was significantly lower comes. It remains wise to follow the U.S. Environ-
in twin gestations, leading the authors to conclude that mental Protection Agency recommendations to avoid
fetal demand for DHA in multiple pregnancies may not highly contaminated fish (eg. shark, swordfish, king
be satisfied by typical dietary intake.54 mackerel, tilefish) during pregnancy. Purified nutri-
Epidemiologic data from the Faroe Islands, tional supplements of fish oil can be used to achieve
where diets are rich in marine oils, suggest that diets the goal of 300 –500 mg daily of DHA. Other sources
with a more favorable ␻-6 to ␻-3 ratio increase birth of ␻-3FA include sunflower, safflower, corn, and
weight through either prolongation of pregnancy or soybean oil, as well as egg yolk, meat, and spinach.
by optimizing the fetal growth rate.55 In prospective Although most nutritional supplement trials in
trials, fish oil supplementation of 2.7g of ␻-3FA daily pregnancy have shown modest effects on the rates of
has been shown to prevent recurrent preterm birth in preeclampsia and preterm birth, at best, these out-
singleton pregnancies (OR 0.54, 95% CI 0.3– 0.98), comes have usually been improved when deficient
with a trend toward a reduction in preterm birth
populations received supplementation. These find-
among twins.56 Smuts et al57 also demonstrated an
ings are likely applicable to twin pregnancy, in which
increase in length of gestation by 6.0⫾2.3 days among
the added demands are typically not met by routine
singleton gestations randomized to receive supple-
dietary intake. Even among middle- to upper-income
mental DHA (133 mg daily) in the third trimester.
Trends for increased neonatal length and head cir- women with advanced education, Turner et al60 dem-
cumference were also noted.57 onstrated that pregnant women (singleton gestations)
Controversy exists as to the risk of contaminants, remain at risk for suboptimal intake of some micro-
notably methyl mercury (MeHg) and polychlorinated nutrients. In this study, the probability of intake less
biphenyls, found in fish that are rich in ␻-3FA. than the estimated average requirement for iron was
Exposure to extremely high levels of MeHg is asso- 91%, zinc 31%, magnesium 53%, and vitamin B6
ciated with microcephaly, seizures, cerebral palsy, 21%.59 Given the likelihood of increased micronutri-
and learning deficiency. Such exposures have oc- ent requirements in twin gestations, high risk of
curred as a result of toxic environmental spills and micronutrient deficiency, and the potential benefit of
deliberate poisoning. However, epidemiologic studies micronutrient supplementation in deficiency states,
from the Seychelles, in which 85% of the population our practice is to recommend the supplement de-
consume ocean fish containing MeHg levels compa- scribed in this review for twin pregnancies.

VOL. 114, NO. 5, NOVEMBER 2009 Goodnight and Newman Twin Nutrition 1129
Given the importance of attention to nutrition in
multifetal gestations, consultation with a registered
dietitian is encouraged if available. The constraints
associated with traditional prenatal care visits usually
do not allow adequate time for in-depth counseling
and education regarding the importance of diet and
adequate nutrition. Nutritional consultation can also
result in the development of individualized BMI-
specific weight gain recommendations, ongoing track-
ing of maternal weight gain, and interventions to
modify maternal diet when women either exceed or
fail to meet their recommended weight gain goals. Fig. 2. University of Michigan Nutrition Intervention Pro-
gram rates of twin pregnancy outcomes (all differences
Surveys of women carrying twins reveal that more P⬍.01). Major morbidity defined as any of retinopathy of
than 25% receive no advice at all regarding weight prematurity, necrotizing enterocolitis, ventilator support, or
gain and that among those who do receive nutritional intraventricular hemorrhage. Very low birth weight, less
counseling, the guidance is often incorrect.61 Clinical than 1,500 g; low birth weight, less than 2,500 g. NICU,
studies have suggested that prenatal care for twin neonatal intensive care unit. (Data from Luke B, Brown MB,
Misiunas R, Anderson E, Nugent C, van de Ven C, et al.
pregnancies provided through specialized, multidisci- Specialized prenatal care and maternal and infant out-
plinary multiple-gestation programs or clinics results comes in twin pregnancy. Am J Obstet Gynecol 2003;189:
in improved maternal and neonatal outcomes.62– 64 A 934 – 8.)
mainstay of these interventions is the grouping of Goodnight. Twin Nutrition. Obstet Gynecol 2009.
women with multiple gestations into specialty clinics
that have a strong emphasis on nutritional evaluation Follow up of the twins at 8, 18, and 36 months
and education in addition to the provision of prenatal demonstrated that children of program nonpartici-
care. pants were more likely to have lagging growth (AOR
In the Michigan Multiples Clinic, women with 1.76, 95%CI 1.26 –2.45) and more likely to be classi-
multiple gestations received prenatal care in a setting fied as developmentally delayed (AOR 1.55, 95% CI
that provides twice monthly dietitian and nurse prac- 1.04 –2.31).63
titioner visits for dietary counseling, along with phy- A similar program was conducted as part of the
sician-directed prenatal care visits. Nutritional modi- Higgins Nutritional Intervention Program conducted
fications emphasized in this program included by the Montreal Diet Dispensary, emphasizing indi-
multimineral supplementation with daily calcium car- vidualized nutrition assessment and similar diet rec-
bonate (3 g), magnesium oxide (1.2 g), zinc oxide (45 ommendations as the Michigan Multiples Clinic. The
mg) in addition to a multivitamin with 100% RDA for Higgins Program demonstrated a 27% reduction in
nonpregnant recommendations (increased to 200% LBW (OR 0.73, 95% CI 0.54 – 0.99) along with a
RDA at 20 weeks).63 The recommended diet compo- reduction in early pregnancy low weight gain (OR
sition included 3,000 – 4,000 kcal/d, composed of 20% 0.49, 95% CI 0.26 – 0.93) in those receiving the inter-
protein, 40% carbohydrates, and 40% fat, divided into vention compared with a matched control popula-
three meals and three snacks daily. Compared with tion.62 Similar trends toward a reduction in very low
nonparticipants, Nutritional Intervention Program birth weight and preterm birth were also noted in the
mothers were more likely to meet weight gain goals at intervention group. Although these studies lacked a
20 and 28 weeks and had fewer pregnancy complica- randomized prospective design, they suggest that estab-
tions (Fig. 2). Program participants also demonstrated lishment of twin pregnancy–specific nutritional recom-
an increase in the length of gestation (13.1 days mendations, together with intensive education and con-
P⬍.001), increased birth weight (435 g, P⬍.001), 7.4 tinued maternal assessment and counseling, can
fewer hospital admission days (P⬍.001), and reduced improve birth weights and prolong the length of gesta-
rates of preterm labor and LBW.62 These reductions tion in twin pregnancies in a cost-effective manner.
in adverse pregnancy outcomes resulted in a cost Finally, does physician input into nutritional ed-
savings of $52,553 in hospital charges per twin pair.63 ucation influence the patient’s attention to proper

1130 Goodnight and Newman Twin Nutrition OBSTETRICS & GYNECOLOGY

nutrition? Although evaluated in few clinical trials in diet modifications for breastfeeding twins; however,
twin gestations, several clinical trials demonstrate that some suggestions may be beneficial. Milk production
provider input into nutritional education is able to may be 1.2–2 L per day by the second month of life
affect maternal weight gain and nutritional status in and require an excess maternal caloric intake of
pregnancy,65,66 and antenatal consultation improves 1,200 –1,500 kcal/d.68 A diet similar to that during
initiation of lactation in twin pregnancy.67 Tools avail- pregnancy is recommended (20% of calories from
able for provider counseling include individual coun- protein, 40% from carbohydrates, and 40% from fat),
seling at prenatal care visits, nutrition or dietitian and continuation of a prenatal vitamin supplement,
referrals, placement and serial review of maternal including DHA is recommended.68 Diets with total
weight gain graphs during the pregnancy in the daily caloric intake during lactation of less than 2,700
obstetric record, and review of dietary recall surveys, cal/d may also be at risk for micronutrient deficiency
which are commercially available. in calcium, magnesium, zinc, vitamin B6, and folate.
Until further specific research is completed, continu-
POSTPARTUM AND BREASTFEEDING ation of micronutrient supplementation as in the
The importance of nutrition for twin gestations does antenatal care of twins into the lactation period is
not end after delivery, because proper nutrition is reasonable to prevent such micronutrient limitations.
necessary to support breastfeeding. Rates of initiation
of breastfeeding in twins can range from 40 –90%, FUTURE RESEARCH
with wide population variation.68 Complications such Several unanswered questions remain regarding the
as prematurity, low birth weight, and neonatal sepsis role of maternal nutrition in improving outcomes in
can adversely affect rates of twin breastfeeding. There twin gestation. The effects of specific diet composition
are few evidence-based recommendations for specific on maternal weight gain and neonatal birth weight

Table 3. Twin Pregnancy Nutritional Recommendations

Intervention First Trimester Second Trimester Third Trimester
Maternal weight/weight gain Assess maternal pregravid Assess/counsel re: maternal Assess/counsel re: maternal
BMI, determine BMI- BMI-specific weight gain (each BMI-specific weight gain (each
specific weight gain goals prenatal care visit) prenatal care visit)
Caloric requirements (kcal·
Normal BMI 40–45 Alter as necessary for weight Alter as necessary for weight
gain goal gain goal
Underweight 42–50
Overweight 30–35
Micronutrient Supplement
(daily total intake)
MVI with iron (30 mg 1 2 2
elemental tablets)
Calcium (mg) 1,500 2,500 2,500
Vitamin D (international 1,000 1,000 1,000
Magnesium (mg) 400 800 800
Zinc (mg) 15 30 30
DHA/EPA (mg) 300–500 300–500 300–500
Folic Acid (mg) 1 1 1
Vitamin C/E (mg/ 500–1,000/400 500–1,000/400 500–1,000/400
international units)
Nutritional consultation Yes Repeat if not at weight gain Repeat if not at weight gain
goal, anemia, GDM goal, anemia, GDM
Laboratory nutritional Hemoglobin ferritin folate/ Follow up abnormalities from Hemoglobin ferritin GDM screen
assessment B12 early screen for GDM first trimester with or without vitamin D
(risk factors) vitamin D
Risk Factor appropriate Screen Screen Screen
exercise or reduction
in activity
BMI, body mass index; MVI, multivitamin; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; GDM, gestational diabetes mellitus.

VOL. 114, NO. 5, NOVEMBER 2009 Goodnight and Newman Twin Nutrition 1131
and body composition can be explored. Systematic 6. Acosta-Rojas R, Becker J, Munoz-Abellana B, Ruiz C, Carreras
E, Gratacos E, et al. Twin chorionicity and the risk of adverse
reviews of nutrient use throughout the twin gestation perinatal outcome. Int J Gynaecol Obstet 2007;96:98–102.
are lacking. Research into the maternal nutrient levels 7. Rosello-Soberon M, Fuentes-Chaparro L, Casanueva E. Twin
associated with optimal fetal growth in early and late pregnancies: eating for three? Maternal nutrition update. Nutr
pregnancy may determine baseline values for screen- Rev 2005;63:295–302.
ing and supplementation as necessary. Evaluation of 8. Krafft A, Breymann C, Streich J, Huch R, Huch A. Hemoglo-
the effect of supplements such as zinc, magnesium, bin concentration in multiple versus singleton pregnancies—
retrospective evidence for physiology not pathology. Eur J
and ␻-3FA on neurodevelopmental outcomes are also Obstet Gynecol Reprod Biol 2001;99:184–7.
needed. Further evaluation of maternal calcium ho- 9. Shinagawa S, Suzuki S, Chihara H, Otsubo Y, Takeshita T,
meostasis and vitamin D metabolism in multiple Araki T. Maternal basal metabolic rate in twin pregnancy.
pregnancies and the effect on bone mineral density of Gynecol Obstet Invest 2005;60:145–8.
the offspring are also warranted. If optimal nutrition 10. Casele H, Dooley S, Metzger BE. Metabolic response to meal
eating and extended overnight fast in twin gestation. Am J
can result in increases in twin birth weights, modest Obstet Gynecol 1996;175:917–21.
prolongations of pregnancy, or neurobehavioral ben- 11. Dietary guidelines for Americans 2005. Available at:
efits as has been suggested in retrospective trials, then Retrieved June 18,
future prospective controlled trials of nutritional in- 2008.
terventions in twin pregnancies are needed. 12. Luke B. Improving multiple pregnancy outcomes with nutri-
tional interventions. Clin Obstet Gynecol 2004;47:146–62.
13. Moore V, Davies M, Willson K, Worsley A, Robinson J.
CONCLUSION Dietary composition of pregnant women is related to size of the
We have discussed the nutritional recommendations baby at birth. J Nutr 2004;134:1820–6.
and evaluation used in our institutions for twin preg- 14. Luke B. Nutrition and multiple gestation. Semin Perinatol
nancies, summarized in Table 3. The current litera-
15. Pederson A, Worthington-Roberts B, Hickok DE. Weight gain
ture supports the benefits of BMI-specific weight gain patterns during twin gestation. J Am Diet Assoc 1989;89:
guidelines specific for twin gestations for improved 642–6.
twin birth weight. Thus our practice is to track 16. Luke B, Gillespie B, Min SJ, Avni M, Witter FR, O’Sullivan
maternal weight gain through the pregnancy and MJ. Critical periods of maternal weight gain: effect on twin
provide nutrition consultation to achieve these goals. birth weight. Am J Obstet Gynecol 1997;177:1055–62.
Twin pregnancy is also at risk for micronutrient 17. Lantz M, Chez RA, Rodriguez A, Porter KB. Maternal weight
gain patterns and birth weight outcome in twin gestation.
deficiency and thus supplementation with iron, cal- Obstet Gynecol 1996;87:551–6.
cium, and folate, beyond a typical prenatal vitamin, is 18. Luke B, Minogue J, Witter FR, Keith LG, Johnson TR. The
recommended. Finally, ␻-3FA dietary intake or sup- ideal twin pregnancy: patterns of weight gain, discordancy and
plementation is also encouraged for potential neuro- length of gestation. Am J Obstet Gynecol 1993;169:588–97.
developmental benefits. Although nutritional inter- 19. Luke B. The evidence linking maternal nutrition and prema-
turity. J Perinat Med 2005;33:500–5.
vention may not reduce all perinatal morbidity
20. Luke B. What is the influence of maternal weight gain on the
associated with twin pregnancy, increased attention to fetal growth of twins. Clin Obstet Gynecol 1998;41:57–64.
specific nutritional needs in twin-specific prenatal 21. Luke B, Hediger ML, Nugent C, Newman RB, Mauldin JG,
care settings have been associated with improved Witter FR, et al. Body mass index–specific weight gains
neonatal outcomes and should be incorporated into associated with optimal birth weights in twin pregnancies.
J Reprod Med 2003;48:217–24.
the prenatal care of twins.
22. Institute of Medicine. Weight gain during pregnancy: reexam-
ining the guidelines. Washington (DC): The National Acade-
REFERENCES mies Press; 2009.
1. Luke B. Reducing fetal deaths in multiple births: optimal 23. Wells C, Schwalberg R, Noonan G, Gabor V. Factors influ-
birthweights and gestational ages for infants of twin and triplet encing inadequate and excessive weight gain in pregnancy:
births. Acta Genet Med Gemellol (Roma) 1996;45:333–48. Colorado, 2000 –2002. Matern Child Health J 2006;10:55–62.
2. Luke B, Minogue J. The contribution of gestational age and 24. Viswanathan M, Siega-Riz A, Moos MK, Deierlein S, Mum-
birthweight to perinatal viability in singleton versus twins. ford S, Knaack, TP, Lux LJ, Lohr KN. Outcomes of maternal
J Matern Fetal Med 1994;3:263–74. weight gain, evidence reports/technology assessment no. 168.
3. Papiernik E, Keith L, Oleszczuk JJ, Cervantes A. What inter- AHRQ Publication Number 08-E-09. Rockville (MD): Agency
ventions are useful in reducing the rate of preterm delivery in for Healthcare Research and Quality; 2008.
twins? Clin Obstet Gynecol 1998;41:12–23. 25. Amorim A, Rossner S, Neovius M, Lourenco PM, Linne Y.
4. Demarini S, Koo W, Hockman E. Bone, lean and fat mass of Does excessive pregnancy weight gain constitute a major risk
newborn twins versus singletons. Acta Paediatr 2006;95:594–9. for increasing long-term BMI. Obesity (Silver Spring) 2007;15:
5. Yildiz A, Balikci E, Gurdogan F. Serum mineral levels at 1278–86.
pregnancy and postpartum in single and twin pregnant sheep. 26. Hininger I, Favier M, Arnaud J, Faure H, Thoulon JM,
Biol Trace Elem Res 2005;107:247–54. Hariveau E, et al. Effects of a combined micronutrient supple-

1132 Goodnight and Newman Twin Nutrition OBSTETRICS & GYNECOLOGY

mentation on maternal biological status and newborn anthro- 43. Mahomed K, Bhutta Z, Middleton P. Zinc supplementation for
pometrics measurements: a randomized double-blind, place- improving pregnancy and infant outcomes. The Cochrane
bo-controlled trial in apparently healthy pregnant women. Eur Database of Systematic Reviews 2007, Issue 3. Art. No.:
J Clin Nutr 2004;58:52–9. CD000230. DOI: 10.1002/14651858.CD000230.pub3.
27. Thomas M, Weisman SM. Calcium supplementation during 44. Briefel RR, Bialostosky K, Kennedy-Stephenson J, McDowell
pregnancy and lactation: effects on the mother and the fetus. MA, Ervin RB, Wright JD. Zinc intake of the U.S. popula-
Am J Obstet Gynecol 2006;194:937–45. tion: findings from the third National Health and Nutri-
tion Examination Survey, 1988 –1994. J Nutr 2000;130:
28. Ritchie L, Fung E, Halloran B, Turnlund JR, Van Loan MD, 1367S–73S.
Cann CE, et al. A longitudinal study of calcium homeostasis
during human pregnancy and lactation and after resumption 45. Makrides M, Crowther CA. Magnesium supplementation
of menses. Am J Clin Nutr 1998;67:693–701. in pregnancy. The Cochrane Database of Systematic
Reviews 2001, Issue 4. Art. No.: CD000937. DOI: 10.1002/
29. Hofmeyr G, Atallah AN, Duley L. Calcium supplementation 14651858.CD000937.
during pregnancy for preventing hypertensive disorders and
46. Rao R, Georgieff M. Iron in fetal and neonatal nutrition. Semin
related problems. The Cochrane Database of Systematic
Fetal Neonatal Med 2007;12:54–63.
Reviews 2006, Issue 3. Art. No.: CD001059. DOI: 10.1002/
14651858.CD001059.pub2. 47. Scholl T, Hediger ML, Fischer RL, Shearer JW. Anemia vs
iron deficiency: increased risk of preterm delivery in a pro-
30. Hofmeyr GJ, Duley L, Atallah A. Dietary calcium supple-
spective study. Am J Clin Nutr 1992;55:985–8.
mentation for prevention of pre-eclampsia and related prob-
lems: a systematic review and commentary. BJOG 2007; 48. Cogswell M, Parvanta I, Ickes L, Yip R, Brittenham GM.
114:933–43. Iron supplement during pregnancy, anemia, and birth
weight: a randomized controlled trial. Am J Clin Nutr
31. Belizan J, Villar J, Bergel E, del Pino A, Di Fulvio S, Galliano 2003;78:773–81.
SV, et al. Long-term effect of calcium supplementation during
pregnancy in the blood pressure of offspring: follow up of a 49. Jackson A, Bhutta ZA, Lumbiganon P. Nutrition as a preven-
randomized controlled trial. BMJ 1997;315:281–5. tative strategy against adverse pregnancy outcomes. Introduc-
tion. J Nutr 2003;133:1589S–91S.
32. Bodnar L, Simhan H, Powers R, Frank M, Cooperstein E,
Roberts J. High prevalence of vitamin D insufficiency in black 50. Charles D, Ness A, Campbell D, Smith GD, Whitley E, Hall
and white pregnant women residing in the Northern United M. Folic acid supplements in pregnancy and birth outcome:
Stated and their neonates. J Nutr 2007;137:447–52. re-analysis of a large randomized controlled trial and update
of Cochrane review. Paediatr Perinat Epidemiol 2005;19:
33. Specker B. Vitamin D requirements during pregnancy. Am 112–24.
J Clin Nutr 2004;80:1740S–7S.
51. Bukowski R, Malone FD, Porter FT, Nyberg DA, Comstock
34. Hollis B, Wagner C. Assessment of dietary vitamin D require- CH, Hankins GD, et al. Preconceptional folate supplementa-
ments during pregnancy and lactation. Am J Clin Nutr 2004; tion and the risk of spontaneous preterm birth: a cohort study.
79:717–26. PLoS Med 2009;6:e1000061.
35. Wagner C, Greer F, American Academy of Pediatrics 52. Genuis S, Schwalfenberg GK. Time for an oil check: the role of
Section on Breastfeeding, American Academy of Pediatrics essential omega-3 fatty acids in maternal and pediatric health.
Committee on Nutrition. Prevention of rickets and vitamin J Perinatol 2006;26:359–65.
D deficiency in infants, children, and adolescents [published
53. Foreman-van Drongelen M, Zeijdner E, van Houwelingen A,
erratum in Pediatrics 2009;123:197]. Pediatrics 2008;122:
Kester A, Al M, Hasaart T, et al. Essential fatty acid status
measured in umbilical vessel walls of infants born after a
36. Bodnar L, Catov JM, Simhan H, Holick M, Powers R, Roberts multiple pregnancy. Early Hum Dev 1996;46:205–15.
J. Maternal vitamin D deficiency increases the risk of pre-
54. McFadyen M, Farquharson J, Cockburn F. Maternal and
eclampsia. J Clin Endocrinol Metab 2007;92:3517–22.
umbilical cord erythrocyte omega-3 and omega-6 fatty acids
37. Chappell L, Seed PT, Briley AL, Kelly FJ, Lee R, Hunt BJ, et and haemorheology in singleton and twin pregnancies. Arch
al. Effect of antioxidants on the occurrence of pre-eclampsia in Dis Child Fetal Neonatal Ed 2003;88:F134–8.
women at increased risk: a randomised trial. Lancet 1999;354:
55. Olsen S, Hansen HS, Sorensen TI, Jensen B, Secher NJ,
Sommer S, et al. Intake of marine fat, rich in (n-3)-polyunsat-
38. Chappell L, Seed PT, Kelly FJ, Briley A, Hunt BJ, Charnock- urated fatty acids, may increase birthweight by prolonging
Jones DS, et al. Vitamin C and E supplementation in women gestation. Lancet 1986;22:367–9.
at risk of preeclampsia is associated with changes in indices of
56. Olsen S, Secher N, Tabor A, Weber T, Walker JJ, Gluud C.
oxidative stress and placental function. Am J Obstet Gynecol
Randomised clinical trials of fish oil supplementation in high
risk pregnancies. Fish Oil Trials In Pregnancy (FOTIP) Team.
39. Poston L, Briley AL, Seed PT, Kelly FJ, Shennan AH, Vita- BJOG 2000;107:382–95.
mins in Pre-eclampsia (VIP) Trial Consortium. Vitamin C and 57. Smuts C, Huang M, Mundy D, Plasse T, Major S, Carlson SE.
vitamin E in pregnant women at risk for pre-eclampsia (VIP A randomized trial of docosahexaenoic acid supplementation
trial): randomised placebo-controlled trial. Lancet 2006;367: during the third trimester of pregnancy. Obstet Gynecol
1145–54. 2003;101:469–79.
40. Casanueva E, Ripoll C, Tolentino M, Morales RM, Pfeffer F, 58. Davidson P, Myers G, Cox C, Axtell C, Axtell C, Shamlaye C,
Vilchis P, et al. Vitamin C supplementation to prevent prema- Sloane-Reeves J, et al. Effects of prenatal and postnatal meth-
ture rupture of the chorioamnionic membranes: a randomized ylmercury exposure from fish consumption on neurodevelop-
trial. Am J Clin Nutr 2005;81:859–63. ment: outcomes at 66 months of age in the Seychelles Child
41. Dietary Reference Intakes. 2007 [cited 2007; Available from: Development Study. JAMA 1998;280:701–7. 59. Hibbeln J, Davis JM, Steer C, Emmett P, Rogers I, Williams C,
42. Black R. Micronutrients in pregnancy. Br J Nutr 2001;85: et al. Maternal seafood consumption in pregnancy and
S193–7. neurodevelopmental outcomes in childhood (ALSPAC

VOL. 114, NO. 5, NOVEMBER 2009 Goodnight and Newman Twin Nutrition 1133
study): an observational cohort study. Lancet 2007;369: 64. Ellings J, Newman RB, Hulsey TC, Bivins HA Jr, Keenan A.
578–85. Reduction in very low birth weight deliveries and perinatal
60. Turner R, Langkamp-Henken B, Littell R, Lukowski M, Suarez mortality in a specialized, multidisciplinary twin clinic. Obstet
M. Comparing nutrient intake from food to the estimated Gynecol 1993;81:387–91.
average requirements shows middle- to upper-income preg- 65. Piirainen T, Isolauri E, Lagstrom H, Laitinen K. Impact
nant women lack iron and possibly magnesium. J Am Diet of dietary counseling on nutrient intake during pre-
Assoc 2003;103:461–6. gnancy: a prospective cohort study. Br J Nutr 2006;96:
61. Cogswell M, Scanlon KS, Fein SB, Schieve LA. Medically 1095–104.
advised, mother’s personal target, and actual weight gain 66. Asbee S, Jenkins TR, Butler JR, White J, Elliot M, Rutledge A.
during pregnancy. Obstet Gynecol 1999;94:616–22. Preventing excessive weight gain during pregnancy through
62. Dubois S, Dougherty C, Duquette M, Hanley J, Moutquin J. dietary and lifestyle counseling: a randomized controlled trial.
Twin pregnancy: the impact of the Higgins Nutrition Interven- Obstet Gynecol 2009;113:305–12.
tion Program on maternal and neonatal outcomes. Am J Clin 67. Friedman S, Flidel-Rimon O, Lavie E, Shinwell ES. The effect of
Nutr 1991;53:1397–403. prenatal consultation with a neonatologist on human milk feeding
63. Luke B, Brown MB, Misiunas R, Anderson E, Nugent C, van in preterm infants. Acta Paediatr 2004;93:775–8.
de Ven C, et al. Specialized prenatal care and maternal and 68. Flidel-Rimon O, Shinwell ES. Breast feeding twins and high
infant outcomes in twin pregnancy. Am J Obstet Gynecol multiples. Arch Dis Child Fetal Neonatal Ed 2006;91:
2003;189:934–8. F377–80.

1134 Goodnight and Newman Twin Nutrition OBSTETRICS & GYNECOLOGY