Nutritional Aspect Of Pregnancy, Lactation, And Infancy

Question 1

What are the consequences of maternal malnutrition?

Answer 1

1. Maternal health
   Increased risk of maternal complications, weakness, infections and death. Deficiency of iron can lead to microcytic anemia and deficiency of folates can lead to macrocytic anemia.
2. Fetal health
   Increased risk of growth retardation, low birth weight, and prematurity. Occurrence of birth defects like NTD, including brain damage and congenital hypothyroidism, in severe cases fetal mortality.
3. Infant during lactation
   Increased risk of growth retardation, negative nitrogen balance and insufficient immune system leading to recurrent respiratory infections

Question 2

What is the recommended intake of calories during pregnancy and lactation?

Answer 2

Pregnancy: Recommended is a moderate increase in steps during the 1st, 2nd and 3rd trimesters (additional 70, 260 and 500 kcal/day).

Lactation: Recommended is continuation with addition of
500 kcal/day during the first 6 months of exclusive breastfeeding

Question 3

What is the recommended intake of macronutrients during pregnancy and lactation?

Answer 3

1. Protein
   Increased dietary intake up to 72 g/day is recommended during pregnancy
   for protein synthesis for maternal tissues, placenta, fetal growth and
   during lactation for milk synthesis. Maternal immunoglobulins are provided to the fetus during pregnancy and dietary to the infant in human milk.
2. Fats
   Increased maternal dietary intake of DHA during pregnancy and lactation
   is highly recommended as DHA is essential for brain and vision development in fetus and infant.
   I
3. Carbohydrates
   No increase of dietary carbohydrates is recommended as this could lead to
   maternal overweight.

Question 4

What are the most micronutrients during pregnancy and lactation?

Answer 4

1. Iron
2. Folate and zinc
3. Calcium
4. VitaminA
5. Iodine

Question 5

Why does iron requirement increase in the 3rd trimester?

Answer 5

The iron requirement increases dramatically in the 3rd trimester and is mainly used for expansion of maternal blood volume and fetal RBC synthesis.
Iron is needed for fetal brain development, myelination and neurotransmitters. The growth of the fetal liver is accelerated and iron is stored to last up to about 6 month after birth.

Question 6

What is the effect of iron requirements of pregnancy & lactation?

Answer 6

Pregnancy: iron supplementation is recommended to prevent maternal microcytic anemia which can also lead to premature delivery and perinatal mortality.

Lactation: the maternal iron demand is normal as human milk is kept low in iron. Human milk contains in addition lactoferrin which binds iron and inhibits growth of iron-dependent bacteria in the GI tract of neonates and infants

Question 7

What are the effects of folate and zinc are essential for cell division?

Answer 7

Folates and zinc
are essential for cell division.

Deficiency of folates before conception or during the first trimester of pregnancy can lead to fetal neural tube defects (NTD) and to maternal anemia.

Increased zinc intake by about 50% is needed to prevent NTD, abortion, stillbirth, preterm delivery, low birth weight (LBW) and small for
gestational age (SGA)

Question 8

Explain the significance of Calcium in infants and fetus

Answer 8

For bone and teeth growth in fetus and infant

Pregnancy and especially lactation are periods of high calcium demand for bone and teeth development. The maternal RDA for calcium intake of 1,200 mg/day is however not increased for women with normal calcium levels.

The reason for this is that the maternal calcium homeostasis changes and leads to more efficient absorption of dietary calcium during pregnancy and lactation. This is regulated by 1,25 dihydroxy vitamin D (calcitriol) and not by dietary calcium.

Lactation, however, leads to a temporary mobilization of calcium from maternal bones. This loss will be refilled after weaning and following increased maternal
estrogen levels

Question 9

Vitamin A and retinoids are essential for…

Answer 9

Growth and cell differentiation, vision and immune system

Question 10

What is the significance of vitamin A and retinoids in pregnancy and lactation ?

Answer 10

Pregnancy: Recommended increase in 2nd and 3rd trimester of the RDA (900 mcg/day) by 10% to improve infant growth and development of skeleton, brain and lung. Deficiency can lead to increased fetal mortality and maternal night blindness.

Teratogenicity: High intake of vitamin A or synthetic retinoids for treatment of acne or psoriasis during pregnancy can be teratogenic (more than 1,500 mcg)
resulting in cleft lip, cleft palate, hydrocephalus and heart malformations.

Lactation: Recommended increase to nearly twice of normal intake to ensure that the milk contains the necessary amount of retinoids for the infant.
Deficiency can lead to xerophthalemia and even to infant blindness

Question 11

Iodine is essential for …

Answer 11

Thyroid hormone synthesis

Question 12

What is iodide used for in pregnancy?

Answer 12

Increased iodine intake by about 50% is needed to prevent spontaneous abortion, perinatal mortality, birth defects and neurological disorders.

Congenital hypothyroidism is characterized by protruding tongue, hoarse voice and growth retardation including the brain. Newborns are screened for iodine deficiency at birth. Early detection of congenital hypothyroidism leads to treatment to prevent irreversible damage (note: the word cretinism should not be used

Question 13

What are toxoplasmosis and listeriosis?

Answer 13

Toxoplasmosis and listeriosis are particularly dangerous during pregnancy.

Toxoplasmosis results from a single-cell human parasite toxoplasma carried by
many animals especially cats. Pregnant women should not clean a cat litter box.

Toxoplasma is also found in contaminated water, raw meat and unpasteurized milk and other food products. It can lead to blindness, hearing loss and brain damage of the baby.

Listeriosis results from contaminated food by the bacterium listeria and in severe cases can lead to miscarriage, premature labor and stillbirth.

Question 14

What are the health risks during pregnancy and lactation ?

Answer 14

Avoid:
Smoking
Alcohol
Drugs (medical drugs if possible) Toxins

Reduce:
Caffeine

Discuss:
Exclusion diets (vegetarian and vegan diet

Question 15

Why should pregnant women avoid smoking?

Answer 15

Avoid smoking
a. Increased risk of preterm delivery and low birth weight of neonate.

b. Increased incidence of asthma and bronchospasm in infants exposed to
smoke even in the prenatal period.

c. Smoking reduces DHA levels in maternal plasma and in milk and leads to
reduced supply to fetus and infant

Question 16

What are exclusion diets?

Answer 16

(vegetarian and vegan diets)
Exclusion diets devoid of any animal food including eggs and milk should be discussed regarding possible deficiency of micronutrients.

Question 17

Aside exclusion diets and smoking, what should pregnant women avoid?

Answer 17

Avoid alcohol (Detail discussed in following slides).

Avoid drugs including medical drugs (teratogenicity).

Avoid toxins like heavy metals and pesticides. High mercury content is found in some fish. Pesticides and herbicides are found in plant food.

Reduce caffeine to less than 1 cup of coffee/day

Question 18

Describe the fetal alcohol metabolism significance

Answer 18

Alcohol passes the placenta and leads to high levels in the fetal circulation.

• Alcohol is differently metabolized in the fetus when compared to adults.
• The synthesis of fetal hepatic enzymes for oxidative ethanol metabolism increases only slowly during fetal development.

• In the fetus, ethanol is enzymatically linked to fatty acids or
other molecules.

• Fatty acid ethyl esters (FAEEs) are excreted in meconium
and can be measured as an early marker for possible
fetal damage by ethanol.

Question 19

What is fetal alcohol syndrome (FAS)?

Answer 19

FAS can lead to physical, cognitive, and behavioral disabilities as it can damage the face, brain or other organs.

Common: facial abnormalities, low birth weight and low intelligence

Question 20

What is Fetal macrosomia ?

Answer 20

Baby weighs more than 8 pounds

Question 21

What causes fetal macrosomia?

Answer 21

Pregnant women do not need to eat for two. Only a moderate weight gain of 25 to 35 lbs is needed for women with a BMI 18.5 - 24.9.

Less weight gain is needed in overweight or obese women.

• It is important to monitor weight gain and to screen and control maternal blood glucose levels.
• Women with hyperglycemia, gestational diabetes and overweight women may deliver a “big baby” with fetal macrosomia.
• Increased risk of injury for mother and baby during delivery. A caesarian section is often required.

• Increased risk for children to develop diabetes, high blood pressure, obesity and
metabolic syndrome

Question 22

Different stages of life after birth need…

Answer 22

Adjusted nutrition

Neonatal up to 28 years old

Premature less than 9 months pregnancy

Infants (babies) are up to 1 year old (Latin word infants means unable to speak)

Question 23

What is unique for nutrition for neonates and infants requires a healthy diet…

Answer 23

At a time of intensive growth

Human milk or formula contains specific macronutrients:

1. Carbohydrates: Lactose (milk sugar)
2. Fat: Fatty acids of the w3 and w6 families.
3. Proteins: Whey and casein with essential amino acids.

Note: If cow milk is used to feed the infant, the diet is increased in proteins. For better digestion cow milk needs to be diluted.

Question 24

What happens to carbs in milk?

Answer 24

Large amount of lactose (milk sugar) which is cleaved in the

small intestine to glucose and galactose by lactase

Question 25

Explain the significance of Congenital Lactase Deficiency

Answer 25

Neonates shall not be breast-fed in case of:
Congenital Lactase Deficiency

Congenital Lactase Deficiency was life threatening in the past due to ingestion of milk which leads to severe osmotic diarrhea and dehydration.

The baby cries due to the painful bloating which is often mistaken for hunger.

Feeding with milk continues to cause pain and damage. These neonates need lactose-free formula as main foo

Question 26

What is the clinical significance of classic Galactossemia?

Answer 26

Neonates shall not be breast-fed in case of:
Classic Galactosemia

Routine analysis of newborns includes urine testing for reducing sugars. Galactose in urine can indicate Classic Galactosemia which results from a rare genetic hepatic enzyme deficiency.

 Characteristics of galactosemia: 
1. Brain damage.
2. Cataracts.
3. Liver and kidney damage.
These neonates need a formula that is lactose-free and also galactose-free

Question 27

How does milk aid the immune system of the infant?

Answer 27

Human milk stimulates the development of a healthy infant’s gut and immune system

The GI tract prior to birth is sterile and the immune system is immature. Human milk provides:

a. Human milk oligosaccharides (HMOs) which are nutrients for “friendly” bacteria: Bifidobacterium infantis and Lactobacillus acidophilus.
b. The enzyme lysozyme which protects the infant against E. coli and Salmonella and promotes the growth of healthy intestinal flora.
c. The immunoglobulin IgA which protects the infant’s intestine against pathogens

Question 28

What is the significance of HMOs?

Answer 28

Human milk oligosaccharides (HMOs)
are food (prebiotics) for friendly bacteria (probiotics).

HMOs fermented by bacteria result in an acidic pH in the gut which makes the environment less suitable for pathogenic bacteria.

Question 29

Summarize levels of Immunoglobins

Answer 29

Pregnancy allows transfer of maternal IgG to the fetus. After birth the infant starts mainly IgM synthesis which is followed by IgG and IgA.

Question 30

What are the fats in human milk?

Answer 30

DHA and arachidonic acid.

DHA (w3) and arachidonic acid (AA, w6) are able to cross the blood-brain barrier of the developing brain and are essential for
brain development and growth and development in vision.

A maternal diet rich in DHA increases DHA in human milk.

Question 31

How is DHA used for brain growth?

Answer 31

Brain growth and DHA
DHA is found in very high concentration in the brain.
DHA is taken up from the blood during pregnancy and after birth from human milk.

Question 32

How does the brain change in the first year of life?

Answer 32

The brain triples in size in the first year of life

The head circumference is measured for normal development.

Question 33

What are the types of proteins in milk?

Answer 33

Human milk has two types of proteins: whey and casein with all
essential amino acids needed for a positive nitrogen balance.

Dietary essential amino acids:

Phenylalanine Valine Tryptophan Threonine Isoleucine Methionine Histidine Arginine ? Lysine Leucine

Question 34

Which amino acids need specifically in large amounts?

Answer 34

Glutamine- nucleotide synthesis

Cysteine- glutathione synthesis

Glycine- heme synthesis

Proline- collagen synthesis

Tyrosine- melanin, hormone synthesis

Question 35

How do Breast fed infants differ between sexes?

Answer 35

A. First 3 months: the baby may gain 2 lbs per month.

B. 6 months: the baby may gain 1 lb per month.

C. 9 months: the baby may gain less than 1 lb per month.