Nutrition during pregnancy

and lactation
dr. Marlina Dewiastuti M.Kes

Nutritional Needs
During Pregnancy
Energy:
First Trimester - no change
Second Trimester - increases 340 kcal/day
Third Trimester - increases 450 kcal/day

Protein:
Increases from 46 g/day to 71 g/day

Vitamin and Mineral

Requirements in Pregnancy

Pregnant women are at increased risk for folic

acid, iron, and calcium deficiencies.

Recommendations are:
Iron increases to 27 g/day
Folate increases to 0.6 mg/day
Calcium - 1000 mg/day
Magnesium - increases to 360 mg/day
Vitamin C - increases to 85 mg/day

Weight Gain and Caloric Intake

Pattern of weight gain during pregnancy is more
important than the total amount of weight gained
It is better to gain the majority of your pregnancy weight
during the last two trimesters

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Weight Gain and Calorie Intake

Do not consume anymore calories than
normal per day during the first trimester
340 additional calories recommended per
day during the second trimester
450 additional calories recommended per
day during the third trimester
Needed for adequate fetal growth and
to support the higher maternal
metabolism

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Recommended Weight Gain

BMI Weight (kg)
Height (m2)

Weight Gain
(kg)

Weight Gain
(lbs)

Underweight
BMI < 18.5

12.7-18.2

28-40

Normal Weight
BMI 19-24.9

11.4-15.9

25-35

Overweight
BMI 25-29.9

6.8-11.4

15-25

Obese
BMI > 30.0

6.8

<15

InstituteofMedicine.WeightGainDuringPregnancy.NationalAcademyPress.1999.

Importance of Good
Nutrition during Pregnancy
Important before, during and after pregnancy
Good control of weight, blood pressure and blood
glucose increase chances of healthy, normal weight,
term infant
Affects fetal and placental growth

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Importance of Good
Nutrition during Pregnancy
Affects maternal well being and maternal outcomes
Not getting enough micronutrients causes low birth
weight, premature birth, and other fetal problems
Micronutrients include: folic acid, iron, omega-3 fatty
acids, Vitamin A, calcium, Vitamin D and iodine

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Neural Tube Defects (NTD)

Prevention: Role of Folate
Folate deficiency is the most common deficiency during pregnancy
Functions:
Serves as a co-factor in one-carbon transfers, (nucleic acids and
amino acids) and therefore required during periods of rapid growth.
Increased maternal erythropoesis causes increased folate needs
during second and third trimesters.

Role in Prevention:
NTD are thought to result from a dietary deficiency of folate and/or a
genetic defect affecting folate metabolism.
During pregnancy, the neural tube is formed from the 18 th to the 26th
DAY of gestation.

Folic Acid
Reduces risk of having a baby with neural tube defects
Reduces the risk of premature birth
Recommended amount of folic acid is 0.4 milligrams (400
micrograms) per day
Most drugstores carry off-brands of this micronutrient
Even some dollar stores carry Folic Acid

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Neural Tube Defects

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Folic Acid
Supplement should be started at least one month before
getting pregnant
It is recommended that any woman of childbearing
age should be taking folic acid supplements because
they may not know they are pregnant until it is too
late.

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Good Sources of Folic Acid

Green leafy vegetables
Fortified cereals

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Iron in Pregnancy
Iron is an essential element in all cells of the body.
During pregnancy, maternal blood volume increases
20-30%.
Iron needs increase from 18 to 27 g/day during
pregnancy.
Deficiency increases risk of maternal and infant
death, preterm delivery, and low birth weight babies.

Iron
Reduces the risk of premature birth and low birth weight
Not getting enough iron could cause anemia
Could contribute to developmental delays and
behavioral disturbances in the infant and poor health
in the mother
Contributes to death and other disease development

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Iron
Essential for normal
infant brain
development
Iron helps create
blood that is
necessary for fetal
demands and blood
loss during delivery.

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Diagnosis of Iron
Deficiency Anemia

The CDC reference criteria for anemia

during pregnancy:
First trimester Hgb <11.0 g/dl or Hct
<33%
Second trimester Hgb < 10.4 g/dl or
Hct <32%
Third trimester Hgb <11.0 g/dl or Hct
<33%

Iron Deficiency Anemia

Weakness, fatigue, poor work performance,
and changes in behavior.
Physical signs include pallor, fatigue,
coldness and paresthesia of the extremities,
greater susceptibility to infections.
Infants and young children with iron
deficiency may have low IQ levels, poor
cognitive and motor development, learning,
and behavioral problems.

Good Sources of Iron

Lean red meat
Green leafy vegetables
Fortified breakfast cereals

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Omega-3 Fatty Acids

Important for brain development and preventing preterm
birth
Essential for visual development
Reduces the incidence of heart disease and heart
related death of the infant
Recommended 300 milligrams per day

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Good Sources of Omega-3 Fatty

Acids
Fish oil capsules
Certain fish such as salmon, trout,
mackerel, sardines, and fresh tuna
Vegetable oils such as sunflower,
rapeseed, flaxseed, and walnut oils

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Calcium and Vitamin D

Calcium and vitamin
D are needed for
strong bones and
teeth
Vitamin D is needed
for the formation of
the fetal bones
Recommended 10
micrograms of
Vitamin D per day
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Good Sources of Calcium and

Vitamin D

Milk and other dairy products

Eggs
Meat
Certain fish such as salmon, trout, mackerel, sardines,
and fresh tuna

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Iodine
Lack of iodine could contribute to stillbirth, birth defects,
and decreased brain development
Iodine is important for brain development

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No Alcohol and Limited

Caffeine
Protect the infant from fetal alcohol syndrome and other
birth defects
Avoid alcohol, including all wines, beers, hard liquor,
and wine coolers
High caffeine intake linked to low birth weight and
spontaneous fetal death
Avoid food and beverages such as teas, coffee, colas,
energy drinks, and chocolate

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 What about smoking?

Women should be discouraged from
smoking before and during pregnancy,
because it is associated with decreased
fertility and lower birthweight.
If women are unable to comply with this
advice, special attention should be paid
to their overall nutrient intake,
especially that of vitamin C, in order to
help counteract the harmful effects of
smoking on the fetus.

What about caffeine?

Claims that consumption of caffeinated
beverages is associated with reduced fertility
and defects in fetal development have not been
substantiated. Whilst moderate intakes (up to
four or five cups of instant coffee a day) are
unlikely to be harmful for most pregnant
women.
those at high risk of miscarriage should reduce
their intake to one or two cups per day.
Cola and tea also contain caffeine and their
consumption should be taken into account.

 Some women experience constipation or

haemorrhoids when they are pregnant.
Can diet help?
These conditions are common during
pregnancy. Practical advice to pregnant
women should be to increase intake of
fibre, by increasing intake of complex
(starchy) carbohydrate, particularly
wholegrain cereals and breads .
An adequate fluid intake is also
important, along with gentle exercise.

Constipation
Constipation during pregnancy is
associated with:
increased progesterone levels and
smooth-muscle relaxation of the GI tract.
This results in GI discomfort, a bloated
sensation, increased hemorrhoids, and
decreased appetite.
Increase fluid and fiber intake to reduce
constipation.

 Nausea and vomiting are common in early

pregnancy. Can diet help?
Morning sickness, nausea and vomiting
occur in around half to threequarters of
pregnant women during the first
trimester.
Consumption of small, frequent meals
can help if these symptoms are
experienced.
Plenty of carbohydrate foods should be
encouraged and plenty of fluids.
A warm drink and a dry biscuit or dry
toast may also be helpful.

Nausea and Vomiting

Associated with increased levels of HCG
Peaks at 12 weeks gestation
Strategies for managing morning sickness:
Eat small, low-fat meals and snacks
Drink fluids between meals, avoid caffeine
Reduce citrus, spearmint, peppermint
Limit spicy and high-fat foods
Avoid lying down after eating or drinking
Take a walk after meals
Wear loose-fitting clothes

What is toxoplasmosis?
Toxoplasmosis is caused by a parasite found in
raw meat, cat faeces and occasionally in
unpasteurised goats milk.
In rare cases, the infection can be passed on to
an unborn baby and cause eye and brain
damage.
A high regard for food hygiene is therefore very
important for pregnant women .
In particular, they should avoid eating raw or
uncooked meat, unpasteurised goats milk or
goats cheese, or unwashed fruit and
vegetables.
After handling raw meat, chopping boards,
utensils and hands should be washed
thoroughly.
When gardening or emptying cat litter trays,
rubber gloves should always be worn.

Physiology of Lactation

Suckling stimulates nipple

--->pituitary gland secretes
oxytocin--->let down reflex
results in milk ejecting cells
contract forcing milk from milk
cells into milk ducts.
Milk pools in lactiferous sinuses
under the areola. Suckling
stimulates milk to come from
the nipple.

Hypothala
mus
Pituitary
Gland
Prolact
in

Oxytoc
in

Uter
us
Myoepith
elial Cell
Lactea
l

General Benefits
of Breastfeeding

Maternal-infant bonding
Inexpensive
Convenient (no preparation)
Perfect temperature
Easily digested
Immunological protection
Allergy prophylaxis

Breastfeeding
Advantages for Mothers

May delay return of ovulation.

Loss of pregnancy associated adipose tissue.
Reduction in postpartum blood loss due to
increased oxytocin levels.
Reduction in pre-menopausal breast cancer
and reduced risk of ovarian cancer.
Improved bone remineralization postpartum.

Immunological Contents
of Breast Milk

Immunoglobulins
IgA, IgG, IgM, leukocytes, cytokines
Host resistance factors
Complement macrophages, lymphocytes, lactoferrin
Anti-inflammatory components
Enzymes: catalase, histaminase, lysozymes,
lactoperoxidase
Antioxidants: acsorbic acid, alpha-tocopherol
Prostoglandins
Interleukin-6
Stimulates an increase in mononuclear cells in breast
milk.

Breastfeeding
Advantages for Baby
Decreased incidence and/or severity of otitis media,
diarrhea, lower respiratory infections, bacteremia,
bacterial meningitis, botulism, urinary tract infections,
and necrotizing enterocolitis.
Less hospitalization in first 6 months.
Possible protective effect against sudden infant death
syndrome, type 1 diabetes, Crohns disease, ulcerative
colitis, lymphoma, allergies, and chronic digestive
diseases.

Composition of Breast Milk

Colostrum: small amount during days 3 to 5
High in protein, immunoglobulins and minerals,
Low in lactose and fat
Transitional milk: produced during days 6 to10
High in fat, lactose
Lower in protein and minerals
Mature milk: available by 2 weeks post-partum
Average secretion: 750 mg/d
Provides 20-22 kcal/ounce
60-80% whey protein, 40% lactose, 50% fat
Growth factor
Low in vitamin D

What is colostrum and how does the composition

of milk change, both during a feed and as the baby
grows?
Colostrum is the first milk produced after the
baby is born.
It is of a different composition to the milk that
follows and is particularly rich in protective
factors and growth factors.
As well as changing in composition over time,
breast milk also changes in composition during
a feed.
The milk available at the start of a feed is richer
in nutrients and energy.

Nutrition and Lactation

Which aspects of diet are particularly important for

women who are breast-feeding?
It has been calculated that breast-feeding
carries a daily energy cost of 650 kcal.
However, some of this is obtained by using up
fat stored during pregnancy for this purpose.
Consequently, women who exclusively breastfeed for 34 months need an extra 500
kcal/day, on average, which corresponds to an
average milk output of 750 ml/day.
Assuming that this extra energy is obtained via
consumption of a balanced and varied diet, the
additional needs for essential vitamins and
minerals will also be met.
Additional requirements for calcium are
particularly high

Nutritional Requirements
During Lactation

Breastfeeding is an anabolic state, resulting in increased energy

and nutrient needs:

500 kcal/day (birth to 6 mo)

400 kcal/day (7 - 9 mo)

Protein, zinc, niacin, vitamins A, E, C requirements increase

above those in pregnancy.

Protein = 71 g/day

Chronically low maternal iron, vitamin B, C, D, thiamin, and folate

intake leads to low content in breast milk.

Should women who are breast-feeding avoid any

particular foods?
Some women report that, after they have consumed
certain foods, e.g. spicy foods or onions, their babies
experience abdominal discomfort.
If this occurs, such foods should perhaps be avoided,
provided omission of the trigger foods does not result
in an unbalanced diet.
Non-nutritive substances such as caffeine, nicotine
and other amines and alkaloids can pass into breast
milk, and heavy consumption of coffee, tea and cola
drinks has been reported to cause restlessness in
some infants.
With regard o the prevention of allergy or other food
intolerance in the baby, the benefits of mothers
avoiding specific foods during pregnancy and
lactation are not proven.
Furthermore, exposure via the mother may be an
important factor in establishing a normal immune
response to proteins in the diet.
Avoidance of foods associated with allergic reactions,
e.g. milk, eggs or nuts, should be seriously
considered only when there is a strong family history
of atopy.

 Is fluid intake important?

An adequate fluid intake is crucial
postpartum for establishing breastfeeding and remains important
throughout, given that, by 23 months
of age, a baby may be taking as much
as 820 ml of milk a day.
The best guide to requirement is thirst,
and forced drinking of extra fluid will not
increase milk quality or quantity.