NUTRITION IN PREGNANCY AND LACTATION · Nutrition in Pregnancy •Adequate nutrition is necessary...
Transcript of NUTRITION IN PREGNANCY AND LACTATION · Nutrition in Pregnancy •Adequate nutrition is necessary...
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NUTRITION IN PREGNANCY
AND LACTATION
Olufemi Aworinde
Consultant Obstetrician and Gynaecologist,
Bowen University, Iwo
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Nutrition in Pregnancy• Adequate nutrition is necessary for development of the infants
metabolic pathway and future well being
• Balanced diet should contain food from all of the basic food groups
• Specifics of diet will vary according to patient's preference, family eating pattern, cultural and ethnic background and social class
• There is increased nutritional need for both fetal growth and maternal physiological needs
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Importance of Nutrition
• Underweight women & low pregnancy weight gain is associated with low birth weight infants(<2500g)
• Statistically significant relationship between low rate of maternal weight gain and preterm delivery
• Overweight women & high pregnancy weight gain are at increased risk of macrosomia(>4000g)
• Macrosomia is associated with birth injuries and caesarean section
• Pre-pregnacy obesity is associated with hypertension, diabetes and post operative wound infection
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Gestational weight gain recommendations
Pre-pregnancy BMI Total weight gain at term Rate of weight gain in the
2nd
and 3rd
trimester
Underweight
(<18.5 kg/m2)
12.5-18 kg 0.51 (0.44-0.58) kg/week
Normal weight
(18.5-24.9 kg/m2)
11.5-16 kg 0.42 (0.35-0.50) kg/week
Overweight
(25.0-29.9 kg/m2)
7-11.5 kg 0.28 (0.23-0.33) kg/week
Obesity
(≥ 30.0 kg/m2)
5-9 kg 0.22 (0.17-0.27) kg/week
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Nutrition in Pregnancy
• Daily requirement related to optimal body weight• 35kcals multiplied by optimal body weight
• About 80000kcal is needed to support full term pregnancy
• These when divided into daily needs give the requirement below.
• Daily requirement• Average non-pregnant woman 2300kcals/d
• Additional 300-350kcals/d during pregnancy
• Additional 300kcals per fetus in multiple pregnancy
• Additional 500kcals/d during lactation
• Some of these nutrients need to be supplemented
• Maternal weight gain in 2nd trimester is the most important for fetal growth• Protective of fetal growth if overall weight gain is poor
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• The amount of food a woman needs during pregnancy
depends on a number of things including her age, BMI before
pregnancy, the rate at which she gains weight and appetite.
• The first trimester does not require any extra calories.
• During the second trimester, an additional 340 calories a day
are recommended.
• For the third trimester, an additional 450 calories a day are
recommended.
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Nutrition in pregnancy
• Total weight gain • 11.5-16kg (ACOG recommendation)
• Average is 12kg
• Underweight need to gain more while obese need to gain less
• Contributors to the weight gain• Fetus 3.5kg
• Placenta, uterus & amniotic fluid 650-900g
• Interstitial fluid & blood volume 1.2-1.8kg
• Breast enlargement 400g
• Maternal fat 1.65kg
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Nutrients
• Nutrients• Macronutrents (protein, carbohydrate and fats & oil)
• Micronutrients (Vitamins and minerals)
• Normal pregnancy diet• Protein 20%
• Fats 30%
• Carbohydrate 50%
• Protein requirement• 1g /kg plus 20g per day in 2nd trimester
• Essential for embryonic development
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Micronutrients
• Multivitamin supplements are not routinely required in a woman eating a well balanced diet
• Iron• 30-60mg elemental iron supplementation is recommended for
pregnancy and lactation
• 60-120mg elemental iron in iron deficiency anemia
• Folic acid• 400ug daily recommendation
• 4mg per day commenced pre-conceptionally for those with previous pregnancy complicated by neural tube defects
• Calcium• 1200mg per day required during pregnancy
• Easily met in diary products
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Folic acid (Summary)
• Strong evidence that folic acid prevents preconceptionally recurrent and first occurence neural tube defects
• Increasing evidence that folic acid reduces risk of some other birth defects
• Improves the hematologic indices in women receiving routine iron and folic acid
• Recommendation• 400 g/day: All women in childbearing age
• 1 mg/day: Pregnant women
• 4 mg/day: Women with history of neural tube defect deliveries (take folic acid 1 month prior to conception and during first trimester)
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Iron supplementation (Summary)
• Iron requirements:• Average non-pregnant adult:
• 800 g iron lost/day
• + 500 g iron lost/day during menses
• Pregnant woman: Increased need
• Expanded blood volume
• Fetal and placental requirements
• Blood loss during delivery
• Routine vs. selective iron supplementation:• Prevalence of nutritional anemia
• Routine iron and folate supplementation where nutritional anemia is prevalent
• Recommended dose: 60 mg elemental iron + 5 g folic acid
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Iodine deficiency• Iodine deficiency is a preventable cause of mental
impairment
• Not common with iodinized salt consumption
• Iodine supplementation and fortification programs have been largely successful in decreasing iodine deficiency conditions
• Population with high levels of mental retardation (e.g., some parts of China):• Supplementation may be effective at preconception up to mid-
pregnancy period
• Form of iodine supplementation (iodinating food or oral/injectable iodine) depend on:
• Severity of iodine deficiency
• Cost
• Availability of different preparation
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Vitamin A supplementation
• Indications for vitamin A supplementation:
• Vertical transmission of HIV (ongoing)
• Infant survival
• Maternal anemia: Positive interaction with iron in reducing anemia
• Infection
• Potential adverse effects of Vitamin A and related substances:
• Excessive doses of Vitamin A (>10,000 IU/day) have been associated with cranial-facial (face, palate, ears) and cardiac birth defects.
• The maximal supplement in pregnancy is 8000 IU/day.
• Offspring of mothers with vitamin A deficiency (which is rare), have a higher mortality rate, which may be associated with decreased immune function.
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Calcium Supplementation
• Calcium decreases risk of hypertension, pre-eclampsia, low birth weight, and chronic hypertension in children
• Recommend for high risk women with low calcium intake, if pre-eclampsia is important in the population
• Calcium has other health benefits not related to pregnancy:• Maintaining bone strength
• Proper muscle contraction
• Blood clotting
• Cell membrane function
• Healthy teeth
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Summary of nutritional review findings
• Evidence of nutritional intervention effectiveness
• Iron supplementation
• Periconceptional folic acid intake
• Iodine use
• Balanced energy/protein supplementation
• Calcium
• Confirmatory studies to examine effectiveness
• Vitamin A
• Zinc
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Breast Feeding
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BREAST
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LYMPHATIC
DRAINAGE
• Lymph nodes
draining the
breast are
located in the
axilla.
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Physiology of lactation Stage Duct system Major hormones
Pre-pubertal None
Pubertal Growth, division and elongation of the tubular duct system
Estradiol
Adult True alveolar development at the ends of the ducts
Oestrogen: Progesterone
1:20 – 1:100
Pregnancy Priming, preparation for milk production
Oestrogen
Progesterone
Prolactin
Human Placental lactogen
Lactation Prolactin
Oxytocin
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The control and production of human milk • Milk is produced as a result of the action of hormones and reflexes
• During pregnancy, hormone changes prepare the gland tissue to make milk. More gland tissue develops and breasts become bigger
• Immediately after delivery, hormone changes make the breasts begin to produce milk (prolactin and oxytocin)
• When baby begins to suckle, two reflexes make the milk come in the right quantity and at the right time
• Prolactin reflex or milk secretion reflex
• Oxytocin reflex or the milk ejection reflex
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The control and production of human milk Prolactin – The milk secreting hormone
• Produced by pituitary gland at base of the brain
• Suckling stimulates the nerve endings in the nipples which carries messages to the anterior part of the pituitary gland
• Works after the baby suckles and makes milk for the next feed
• Production based on supply and demand
• Pituitary secretes more prolactin during the night –breast feeding at night helps to keep up a good supply
• Prolactin suppresses the activity of the ovaries –contraception and delays menstruation
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The control and production of human milkOxytocin – The milk ejecting hormone
• Makes small muscle cells around the breast glands contract and increase the pressure on the milk inside
• Produced when the baby suckles and stimulates the sensory nerves in the nipple
• Secreted by the posterior part of the pituitary gland
• Works while the baby is suckling and makes milk flow for this feed
• Makes uterus to contract – helps to deliver placenta
• Helps to stop bleeding immediately after delivery - Shortens time mother loses lochia
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The control and production of human milk
Oxytocin – The milk ejecting hormone…
• Mother’s thoughts, feelings and sensations can affect the oxytocin’s reflex.
• Helping milk ejection
• Love thoughts
• Cry of baby
• Perceived confidence
• Hindering milk ejection
• Worries and fears
• Pain especially painful breastfeeding
• embarrassment
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The control and production of human milk • How milk “comes in”
• 1st few day – breast secretes colostrum
• Next few days (2-7days) – breast begins to feel full
and produce a lot of milk (“milk comes in”). This
happens more quickly if feeding is unrestricted or on
demand
• Next few days – breast feels less full and softer but
continues to produce plenty of milk
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Breast feeding
• A healthy full-term baby has three reflexes which help
him to feed
• Rooting reflex
• Helps baby to find the nipple - baby turns towards
the nipples when something touches the baby near
its mouth
• Suckling reflex
• When something goes into baby’s mouth far
enough and touches his palate, he sucks it
• Swallowing reflex
• If a baby’s mouth fills with milk, he swallows it
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Breast feeding (Benefits)
• Cheap, accessible
• Bonding
• Reduced juvenile-onset diabetes mellitus, inflammatory bowel disease and neoplastic disease in childhood
• Fertility regulation • Child spacing
• Contraception• Within six months of delivery
• Exclusive breastfeeding
• amenorrhoea
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Breast feeding (Benefits)
• Nutritional benefits
• Protection against infections• Reduced incidences of vomiting and diarrhoea
• Protection against respiratory tract infections
• Has high amount of lactoferrin, which binds iron required for growth by E Coli
• Encourages growth of non-pathogenic organisms in gut
• Ig A not absorbed in gut and then binds offending organisms
• Contains polymorphs, lymphocytes and plasma cells
• Neurological benefit• Improved cognition
• Reduced atopic illnesses
• Reduced breast cancer among mothers who breastfed
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Breast feeding
• Exemption from breastfeeding• Drugs & alcohol abuse
• Infant with galactosemia
• HIV infected mother
• Active untreated tuberculosis
• Women being treated for breast cancer
• Some drugs contraindicated during breastfeeding• Cyclophosphamide, doxorubicin,
• Phencyclidine
• Lithium
• Cyclosporin
• Radioactive iodine
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Suppression of lactation
• Tight breast binding
• Avoidance of tactile breast stimulation
• Ice packs
• Mild analgesics
• Aspirin
• ibuprofen
• Drugs
• Bromocriptine (10-14 days)
• Oestrogen
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Problems with lactation
• Psychological stress
• Breasts engorgement
• Mastitis
• Breast abscess
• Nipple retraction
• Inadequate milk production
• Excretion of drugs in breast milk
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Breast feeding and mothers medicines
• Drugs that decrease milk supply
• Oestrogens
• Thiazide diuretics
• Bromocriptine
• Drugs that increase milk supply
• Chlorpromazine – 25mg dly for a week
• Metoclopramide – 10-15mg three time a day for up to 3 months
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Myths and taboos
• No breast feeding when there is breast abscess
• Don’t breast feed when pregnant with another baby
• Sexual intercourse harms milk
• Dangerous to breast feed during menstrual period
• Mother believes she cannot breast feed when ill
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Counselling and support
• Concern for well being of the mother
• Antenatal preparation
• Psychological
• Physical preparation
• Family preparation for support especially husbands
• Postpartum advice
• Preparing mother to leave hospital
• Concern at postnatal appointment
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Conclusion
Breastfeeding…..
• Best and safest way of feeding infants
• Sweet and plentiful breastmilk is the perfect food;
always ready, warm and delicious. And it comes
in an attractive and time-tested package; that of
the woman’s breast; firmly attached to the warm,
soft, breathing, beating body of the mother.
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THANK YOU!
THANK
YOU!THANK
YOU!