Chapter 11 – Nutrition through the Life Span: Pregnancy and Lactation

Lecture Outline

I. Pregnancy: the Impact of Nutrition on the Future

A. Nutrition Prior to Pregnancy
1. Nutrition prior to pregnancy focuses primarily on women
2. Full nutrient stores prior to pregnancy: essential to conception & healthy infant development
3. Developmental changes occur during early weeks of pregnancy—even before the pregnancy
is evident
4. Young adults need to nourish & protect their bodies for their own sakes & that of future
generations
5. Habits to establish in preparation for healthy pregnancy:
a. Achieve & maintain a healthy body weight
b. Choose an adequate & balanced diet
c. Be physically active
d. Avoid harmful influences
6. 2005 Dietary Guidelines – Women of childbearing age who may become pregnant should:
a. Eat foods high in heme-iron &/or consume iron-rich plant foods or iron-fortified foods
b. Consume adequate synthetic folate daily from fortified foods or supplements
B. Pre-pregnancy Weight
1. Appropriate weight prior to pregnancy benefits pregnancy outcome
2. Underweight & overweight both present medical risks
3. Underweight
a. Underweight women: higher risk of having low-birthweight infant
b. Low-birthweight infants have increased risk of acquiring diseases or dying in first month
of life
c. Impaired growth & development during pregnancy may have long-term health effects
d. Poor nutrition is major factor in low birthweight
e. Weight gain prior to pregnancy is advised
f. Infant & child mortality rates
1. Nutritional deficiency & low birth weight contribute significantly on worldwide
basis
2. U.S. infant mortality: 7.0 deaths per 1000 live births (2002)
3. Significant public health efforts to reduce infant mortality
4. Steady decline in last decades
3. Overweight & obesity
a. Infants (of obese mother)
1. May be larger than normal, even when premature
2. Twice as likely to be born with neural tube defects
3. Incidence of heart defects & other abnormalities more likely
b. Obese women
1. More likely to require medication or surgical intervention for birth
2. Increased complications, including gestational diabetes, hypertension, post-partum
infection

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 c. Goal: strive for healthy pre-pregnancy body weight to minimize risks to mother &
infant
C. Healthy Support Tissues
1. Healthy development of the placenta depends on adequate pre-pregnancy nutrition
2. Support tissues: Uterus, placenta, umbilical cord, amniotic sac
D. Events of Pregnancy
1. Fertilization & cell division
a. Fertilized ovum (zygote): single cell that divides at rapid rate
b. Implantation
c. Zygote embeds itself in uterine wall; placental development begins
d. Crucial time of development, even as growth is minimal
e. Adverse influences can lead to
1. Failure to implant
2. Abnormalities, such as neural tube defects, or loss of zygote
2. Embryonic & fetal development
a. First 6 weeks: rapid physical changes of embryo
b. At 8 weeks
1. Complete nervous system, digestive system
2. Well-defined fingers & toes, beginnings of facial features
c. Last 7 months: fetal stage – Growth stage in weight & length
d. Critical period of cell division & development of multiple organs
3. Infant birth
a. 39-41 weeks for full gestation
b. Birth weight of 6 ½-9 pounds
4. Critical periods
a. Each organ & tissue develops in its own pattern & timing
b. Development of each takes place only at specific time—critical period
c. Required nutrients & environmental conditions necessary during this period
d. Malnutrition during period impairs organ development
e. Effects are irreversible
f. Effects of malnutrition during critical periods
1. Defects of nervous system in embryo
2. Poor dental health for child
3. Vulnerability as adolescent & adult to infection
4. Risks of diabetes, hypertension, stroke, heart disease
E. Nutrient Needs during Pregnancy
1. Overall energy requirements
a. Vary by stage of pregnancy
b. 1st trimester—no additional energy
c. 2nd trimester—additional 340 kcalories per day
d. 3rd trimester—additional 450 kcalories per day
e. Can be met in several ways
1. Eat more food
2. Reduce physical activity
3. Store less food energy as fat
4. Select more nutrient-dense foods from the 5 food groups

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2. Carbohydrate
a. Nutrient-dense choices since nutrient need is greater than increased energy needs
b. Whole-grain breads & cereals, legumes, dark green vegetables, citrus fruits, low-fat milk
& milk products, lean meats, fish, poultry & eggs
c. Ideally 175 grams per day (minimum - 135 grams)
d. Fiber can help alleviate constipation
3. Protein
a. RDA – 25 grams higher than for nonpregnant women
b. Vegetarian women include several servings of plant-protein foods
c. Protein supplements are not recommended
4. Fats
a. Essential fatty acids necessary: omega-3 & omega-6 fatty acids
b. Limit saturated fats
5. Folate & vitamin B12
a. Specific roles in cell reproduction
b. New cells laid down as fetus grows & develops
c. Maternal blood volume increases, requiring increase in red blood cells
d. RDAs
1. Folate: 600 µg per day
2. Vitamin B12: 2.6 µg per day
e. Neural tube defects
1. Inadequate folate intake
2. Incidence of neural tube defect in previous pregnancy
3. Maternal diabetes
4. Maternal use of antiseizure medication
5. Maternal obesity
6. Exposure to high temperatures during pregnancy
7. Race/ethnicity
8. Low socioeconomic status
f. Folate-rich sources
1. 400 µg of folic acid supplement, fortified foods or both (in addition to folate-rich
foods)
2. Enriched grain products
3. Liver
4. Lentils, chickpeas, pinto beans
5. Asparagus, spinach, beets
6. Avocado
7. Orange juice
g. Vitamin B12
1. Women who consume meat, eggs or dairy products can meet all of vitamin B12 needs
2. Those who exclude all animal products from diet require fortified foods or
supplements
6. Calcium
a. Increased demand during pregnancy
b. Abnormal fetal bone development may result from insufficient intakes
c. More than 300 mg per day of calcium are transferred to the fetus during final weeks

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 d. Calcium recommendations are aimed at conserving mother’s bone mass while supplying
fetal needs
e. Recommendations for calcium & vitamin D
1. Milk products offer advantages over supplements
2. Inclusion of calcium & vitamin D-fortified foods
3. Women <25 years require more calcium
4. Increase intake of milk, cheese, yogurt, other calcium-rich foods
5. Less preferable option: 600 mg supplement daily
7. Fluoride
a. Required for mineralization of fetal teeth & bone development
b. Excesses may be harmful, however
c. Supplements not recommended for women who drink fluoridated water
d. Fluoride AI during pregnancy: 3.0 mg/day
8. Iron
a. Body conserves iron well during pregnancy
1. Menstruation ceases
2. Absorption of iron increases
b. However, needs are so high that stores dwindle
c. Iron RDA: 27 mg/day
d. Sources
1. Liver, oysters
2. Red meat, fish, other meats
3. Dried fruits
4. Legumes
5. Dark green vegetables
e. Vitamin C-rich foods enhance iron absorption from foods
f. Supplement during 2nd & 3rd trimesters
9. Zinc
a. Required for DNA & RNA (& thus), protein synthesis
b. Severe deficiency predicts low infant birth weight
c. Zinc RDA: 12 mg/day (≤18 years); 11 mg/day (19-50 years)
d. Sources: Foods of high protein content
10. Nutrient supplements
a. Prenatal supplements provide more folate, iron & calcium than regular supplements
b. Especially indicated for women
1. With inadequate diet
2. Carrying multiple fetuses
3. Who smoke cigarettes, or are alcohol or drug abusers
F. Food Assistance Programs
1. WIC Program
a. Special Supplemental Food Program for Women, Infants & Children
b. Federal program for low-income pregnant & lactating women & their children
c. Foods provide nutrients that are often lacking
d. Milk, cheese, iron-fortified cereals, fruit or vegetable juices, carrots, eggs, dried beans,
tuna, peanut butter
e. Iron-fortified formula for bottle-fed infants

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 f. Encourages breast feeding, offering incentives to mothers who do
2. Other programs
a. Food stamp program
b. Community food & educational assistance programs
c. American Dietetic & American Diabetes Association, others provide nutritional
information
G. Weight Gain
1. Fetal & maternal well-being depend on weight gain during pregnancy
2. Ideally, healthy weight at start of pregnancy
3. More important, weight gain within recommended range, based on prepregnancy BMI
4. Patterns of weight gain
a. For normal-weight woman: about 3 ½ lb gain during 1st trimester, then 1 lb/week
b. Weight gains within recommended ranges associated with fewer surgical births, greater
number of healthy birthweights, other positive outcomes
5. Dieting during pregnancy not recommended (even obese women should gain at least 15 lb)
6. Essential for healthy pregnancy
a. Pregnant adolescent needs weight gain to accommodate for her own growth, as well as
that of fetus
b. Women with multiples require still more gain
7. Sudden, large weight gain is danger signal for preeclampsia
8. Weight gain is nearly all lean tissue: Placenta, uterus, blood, milk-producing glands, fetus
9. Fat gain needed later for lactation
10. Physical activity can help to cope with extra weight
H. Physical Activity
1. Staying active during course of pregnancy
a. Improves fitness of mother-to-be
b. Aids to carry extra weight
c. Eases upcoming childbirth
d. Helps prevent or manage gestational diabetes
e. Reduces psychological stress
f. Associated with fewer discomforts during pregnancy
g. Helps with loss of weight & regaining fitness after delivery
2. Choice of activity
a. Low-impact
b. Avoidance of sports where falls or trauma is risk
c. Frequency, duration & intensity of activity affects benefits & risks
d. Avoid activities that will result in high internal body temperature & dehydration
3. 2005 Dietary Guidelines
a. Moderate-intensity activities
b. 30 minutes or more most, if not all days
c. Avoid activities with risk of falling or abdominal trauma
I. Common Nutrition-Related Concerns of Pregnancy
1. Food cravings & aversions
a. Individual cravings do not seem to reflect real physiological needs
b. Cravings & aversions probably due to hormone-induced changes in taste & sensitivity to
smells

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 2. Pica: non-food cravings
a. Cravings for items such as laundry starch, clay or soil, ice
b. May be practiced for cultural reasons; common among African-American women
c. Often associated with iron deficiency
3. Morning sickness
a. Usually benign condition
b. Ranges from mild nausea to debilitating problem
c. May be aggravated by smells
d. Cause: increased hormonal changes early in pregnancy
e. Measures to alleviate
1. On waking, get up slowly
2. Eat dry toast or crackers
3. Chew gum or suck hard candy
4. Eat small, frequent meals whenever hunger strikes
5. Avoid foods with offensive odors
6. Avoid citrus juices, water, milk, coffee, tea when nauseated
4. Heartburn
a. Burning sensation in lower esophagus, near heart
b. May also cause burning sensation in throat
c. Common, benign condition
d. Cause: reflux of stomach acid as fetus grows & exerts pressure against woman’s stomach
e. Relief measures
1. Relax & eat slowly
2. Eat small, frequent meals
3. Drink liquids between meals
4. Avoid spicy & greasy foods
5. Sit up while eating
6. Wait an hour after eating before lying down
7. Wait 2 hours after eating before exercising
5. Constipation
a. Cause: hormones alter muscle tone, growing infant crowds intestinal organs
b. Harmless, benign condition
c. Relief measures
1. Eat foods high in fiber
2. Exercise daily
3. Drink at least 8 glasses of liquids a day
4. Respond promptly to urge to defecate
5. Use laxatives only as prescribed
6. Avoid mineral oil
J. Problems in Pregnancy
1. Gestational diabetes
a. Pregnancy-related form of diabetes
b. Usually resolves after infant is born
c. Some women develop type 2 diabetes later, especially if overweight
d. Can lead to fetal or infant sickness or death
e. Early diagnosis & management reduces risks

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 f. May result in surgical birth & high infant birth weights
g. American Diabetes Association: all women should be assessed for risk at first prenatal
examination
h. Risk Factors: Obesity, personal history, family history, glucose in urine
i. Racial & Ethnic Tendency – Hispanic American, Native American, Asian American,
African American, Pacific Islander
2. Hypertension
a. Complicates pregnancy
b. Effect on outcome depends on when problem develops & how severe it becomes
c. Associated with health risks of heart attack & stroke
d. May be warning sign for preeclampsia
3. Preexisting chronic hypertension
a. Common associated risks
1. Low-birthweight infant
2. Premature separation of placenta from uterine wall, resulting in stillbirth
b. Ideally, BP should be under control before pregnancy
4. Transient hypertension of pregnancy
a. Increase in BP, usually occurring during second half of pregnancy
b. Usually mild, with little adverse effect on pregnancy
c. BP usually returns to normal within few weeks after childbirth
5. Preeclampsia
a. Serious complication; may progress to more serious eclampsia
b. Characteristics
1. High blood pressure
2. Protein in urine
3. Fluid retention (edema) of entire body
c. Incidence
1. Affects <10% of women
2. Usually during first pregnancy, after 20 weeks gestation
d. Symptoms usually regress within 48 hours after delivery
e. Affects almost all organs
f. Warning Signs of Preeclampsia
1. Hypertension
2. Protein in urine
3. Upper abdominal pain
4. Severe & constant headaches
5. Swelling, especially of face
6. Dizziness
7. Blurred vision
8. Sudden weight gain (1 lb/day)
6. Eclampsia
a. Severe complication
b. Associated with convulsions
c. Common cause of maternal mortality
d. Treatment focused on controlling preeclampsia
e. Regulating blood pressure

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 f. Preventing convulsions
K. Practices to Avoid
1. Cigarette smoking
a. Parental smoking can kill an otherwise healthy fetus or newborn
b. Effects
1. Damage to fetal chromosomes
2. Restricts blood supply to fetus
3. Limits delivery of oxygen & nutrients, removal of wastes
4. Slows growth
5. May cause behavioral or intellectual problems
6. May complicate birth
7. Low infant birth weight
8. Has been linked to SIDS
c. Exposure to environmental tobacco smoke (ETS, or second-hand smoke) creates risk,
even in non-smoking mother
2. Medicinal drugs & herbal supplements
a. May result in serious birth defects
b. All OTC or non-prescribed drugs should be avoided
c. Herbal supplements may not be safe alternative
1. Limited testing for safety & efficacy during pregnancy
2. All should be avoided unless safety during pregnancy has been ascertained
3. Drugs of abuse
a. Abuse of drugs may cause serious health consequences for fetus
b. Easily cross placenta
c. Impair fetal growth & development
d. Low birth weight
e. Heartbeat abnormalities
f. Pain of withdrawal
g. Death
h. Fetal effects of abused drugs
1. Nervous system damage (amphetamines)
2. Behavioral abnormalities (amphetamines)
3. Drug withdrawal symptoms (barbiturates, opiates)
4. Uncontrolled jerking movements or paralysis (cocaine)
5. Permanent mental & physical damage (cocaine, opiates)
6. Irritability at birth (marijuana)
7. Permanent learning disabilities, ADD, ADHD (opiates)
4. Environmental contaminants
a. Lead & mercury
b. Readily cross placenta
c. May cause fetal nervous system damage
d. May result in impaired mental development
e. FDA & EPA advisory regarding mercury concentrations in fish
1. Avoid large ocean fish
2. Eat up to 12 oz a week of safer fish & shellfish: canned light tuna, salmon, pollock,
catfish, shrimp

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 3. Smaller portions for children
f. Albacore tuna contains more mercury than light tuna; limited to 6 oz or less per week
g. Check local advisories about safety of fish from lakes, rivers & coastal areas
5. Food borne illness
a. Vomiting & diarrhea from food borne illness may cause fatigue & dehydration
b. Listeriosis: more threatening
1. May cause miscarriage, stillbirth, severe brain damage, infections in fetus or newborn
2. Pregnant women more likely than other healthy adults to acquire listeriosis
3. Prompt treatment to prevent fetal or newborn infection
c. 2005 Dietary Guidelines
1. Pregnant women should not eat or drink unpasteurized milk, milk products, juices;
raw or undercooked eggs, meat or poultry; raw sprouts
2. Pregnant women should only eat certain deli meats & frankfurters that have been
reheated to steaming hot
6. Vitamin-mineral megadoses
a. Many vitamins & minerals toxic when taken in excess
b. Vitamin A closely linked with birth defects
c. Additional vitamin A not recommended during pregnancy
7. Dieting
a. Weight loss dieting, even short term, is hazardous to pregnancy
b. Low carbohydrate intake deprives fetal brain of needed glucose; may impair
development
8. Sugar substitutes
a. Considered acceptable to use if within FDA guidelines
b. Still wise to use in moderation & within nutritious, well-balanced diet
c. Women with PKU should not use aspartame
9. Caffeine
a. Crosses placenta
b. Fetus has limited ability to metabolize
c. No limit available, heavy use may increase risk of fetal death (studies show)
d. Limit to 1 cup of coffee or two 12-oz beverages per day
10. Alcohol
a. Fetal alcohol syndrome (FAS)—spectrum of symptoms
1. Irreversible brain damage
2. Growth & mental retardation
3. Facial & vision abnormalities
4. Other health problems
b. Most severe impact in first 2 months of pregnancy
c. American Academy of Pediatrics: women should stop drinking as soon as they plan to
become pregnant
d. “Safe” alcohol intake limit during pregnancy has not been established
L. Adolescent Pregnancy
1. Special case of intense nutrient needs associated with adolescent pregnancy
2. Hard to meet nutritional needs for rapid growth & development during adolescence
3. Many teens enter pregnancy with multiple deficiencies—putting both mother & fetus at risk
a. Vitamins A & D, folate

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 b. Iron, calcium, zinc
4. Higher incidence of miscarriage, premature births, stillbirths, low-birthweight infants, infant
death
5. Adequate nutrition—indispensable component of prenatal care for adolescents
a. Weight gain of about 35 lb (BMI in normal range before pregnancy)
b. Adequate kcalorie intake

II. Breastfeeding
A. Introduction
1. American Academy of Pediatrics & American Dietetic Association recommendations
a. Exclusive breastfeeding for first 6 months
b. Breastfeeding with complementary foods for at least 12 months
2. Breast milk—unique nutrient composition & protective factors promote optimal infant health
& development
3. Iron-fortified formula is only acceptable alternative to breast milk
B. Nutrition during Lactation
1. General guidelines for lactating women
a. Continue to eat nutrient-dense foods
b. Do not restrict weight gain unduly
c. Enjoy ample food & fluids at frequent intervals
2. Energy
a. Milk production requires about 500 kcalories per day over regular need during first 6
months
b. Add extra 330 kcalories per day
c. Remaining 170 kcalories can come from fat stores
3. Weight loss
a. Breastfeeding for 3+ months may accelerate weight loss
b. Also affected by percentage of body fat & weight gain during pregnancy
c. General loss of 1-2 pounds per month for first 4-6 months
d. Moderate weight loss does not affect quality or quantity of breast milk
e. Diet & physical activity will improve weight loss & fitness
4. Vitamins & minerals
a. Women generally can produce milk with adequate protein, carbohydrate, fat, folate,
most minerals
b. Milk quality maintained at expense of maternal stores
c. Some nutrients decline in response to long-term inadequate intake of vitamins (especially
vitamins B6, B12, A, D)
5. Water
a. Volume of milk produced depends on infant demands—not amount of fluid mother
drinks
b. Still recommend fluid intake of about 13 cups per day
6. Particular foods
a. Some infants are sensitive to foods in mother’s diet
b. If food causes discomfort, it can be eliminated from diet to evaluate problem

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 C. Contraindications to Breastfeeding
1. Alcohol
a. Enters breast milk
b. Adversely affects production, volume, composition & ejection
c. Overwhelms infant’s immature alcohol-degrading system
d. May alter taste & result in less consumption
2. Caffeine
a. Can result in wakefulness & jitteriness in infant
b. Consumption should be moderate
3. Cigarette smoking
a. Results in less milk production & lower fat content
b. Exposes infant to nicotine & other chemicals in breast milk; sidestream smoke
c. May result in array of health problems
4. Medications & illicit drugs
a. Medications may be secreted in breast milk
b. Breastfeeding should be withheld during period of medication treatment
c. Sustain flow of milk by pumping breasts & discarding milk
d. Some medications may have no effect on infant, but should only be taken with
physician’s direction
e. Use of illicit drugs may result in infant addiction
f. Contraceptives may or may not affect breast milk
5. Maternal illness – Contraindications to breastfeeding:
a. Active, untreated tuberculosis
b. Administration of radioactive isotopes
c. HIV & AIDS infections

III. Successful Breastfeeding

A. Many health care organizations recommend exclusive breastfeeding for first 6 months
1. Exclusive = infant consumption of human milk with no supplementation (no water, other
type of milk, juice, other foods)
2. Exception: vitamins, minerals & medications
3. Continue breastfeeding for at least 1 year & thereafter
4. Increasing rates of breastfeeding initiation & duration is goal of Healthy People 2010
a. Increase proportion of mothers who breastfeed immediately after birth, for 6 months;
preferably 1 year
b. Increase proportion of mothers who breastfeed exclusively
5. Despite recommendations, percentage of women who breastfeed continues to be low
B. Deterrents to breastfeeding
1. Public advertising of infant formula
2. Medical community’s failure to encourage
C. Information & instruction especially important during prenatal period when decision is being
made
1. Nurses, other professionals play crucial role
2. Encouragement & assistance need to be provided in hospital & after discharge

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 D. Teaching mothers about breastfeeding
1. Preparation
a. Discontinue use of soaps & lotion on breasts toward end of pregnancy & throughout
lactation
b. Acquire at least 2 nursing bras before delivery
c. Begin breast feeding immediately after delivery, or as soon as possible
2. Continuation of successful breastfeeding
a. Learn how to relax & position self & infant
b. Stimulate rooting reflex
c. Support breast & position nipple
d. Allow nursing for 10-15 minutes on each breast
e. Feed on demand, rather than rigid schedule—averaging 8-12 feedings per 24-hour period
during 1st month
E. Problems associated with breastfeeding
1. Sore nipples
2. Engorgement
3. Mastitis

Activity 11-2: Field Exercises

Examine the prenatal nutritional supplements available at a local drug store, supermarket or pharmacy.
Note the composition of each and its cost. Ask the pharmacist for his or her opinion about nutritional
supplements in pregnancy and the questions pregnant women ask about supplements.

Interview a breastfeeding mother of an infant to determine her food habits. Do a 24-hour recall and
analyze the results using the class nutritional analysis software or a Web page offering the analysis
feature. Assess whether the diet is adequate for lactation.

Obtain a copy of the handout on infant feeding for new mothers from the local public health department.
Some students may be able to attend a well baby clinic to observe the public health nurses in action
dispensing advice about infant feeding. Discuss the results of the field trip and the rationale behind the
information in the pamphlet.

Activity 11-3: Review of ADA Position Papers

Have students access the ADA website at www.eatright.org and review the position papers on nutrition
care for pregnant adolescents and promotion and support of breastfeeding, and summarize the
information in the papers for the class.

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