Pregnancy & Infancy Flashcards
What are the 9 major stages of the human lifecycle?
1. Preconception 2. Pregnancy 3. Lactation 4. Infancy 5. Toddler years 6. Childhood 7. adolescence 8. Adulthood 9. Senior years
What is the definition of ageing?
the physiological changes that the body undergoes over the course of a lifetime (psychosocial, personal, moral, cognitive & spiritual growth & development)
What are the 4 ways to define ‘old’?
biologically, psychologically, socially & chronologically (65y +)
How will new Zealand’s ageing population change in by 2043?
- number of people aged 65+ will double
2. number of people aged 85+ will triple
What does it mean to consider ageing as a disease?
Focus on preventing & treating
What is ageing due to?
errors in their DNA accumulating into tissue damage
What factors influence the rate ageing occurs?
Genetic & environmental factors
What is the majority of a baby health determined by?
The environment
What is the minority of a baby health determined by?
Genes
What is the critical window of opportunity for healthy brain development, healthy growth & a strong immune system?
First 1000 days (pregnancy + 2 years)
What is preconception?
The period before pregnancy
What is periconception?
The period immediately following human conception
What are the 5 stages of reproductive reproduction?
- Gametogenesis
- fertilisation
- implantation
- embryogenesis
- placentation
What lifestyle factors that contribute to long term health prior to conception?
Supplement iodine & folic acid, cease smoking, restore normal weight, follow a healthy diet, optimise health
What is the cost of reproduction?
Greater energy expenditure due to nourishing offspring
What does inadequate body fat cause or a 10-15% decrease in body fat?
Low luteinising hormone & estradiol = hypothalamic amenorrhea
What is low levels of body fat during adolescence is related to
Delay in the age of menstruation onset
What risk factors arise from undernutrition in early pregnancy?
Poor glucose metabolism, obesity, poor lipid profile, blood coagulation, coronary heart disease, breast cancer, stress responsiveness, cognition, depression
What risk factors arise from undernutrition in mid pregnancy?
Altered Glucose metabolism, lung-disease, altered renal function
What risk factors arise from undernutrition in late pregnancy?
Altered glucose metabolism
What were children of pregnant women exposed to famine more susceptible of?
diabetes, obesity, CVD, microalbuminuria; epigenetic changes passed down through generations
What risks are associated with over supplementation of folic acid?
increased risk of asthma, atopic dermatitis, obesity & metabolic syndrome
What is an imbalance between folic acid & b12 associated with?
intrauterine, growth restriction, reduced cognitive function & increased risk of adiposity & diabetes
What is the Barker hypothesis?
Foetal undernutrition in middle to late gestation, which leads to disproportionate foetal growth associated with later coronary heart disease
What is thrifty phenotype hypothesis?
During periods of starvation foetus reduces insulin secretion, increases peripheral insulin resistance, directing more glucose to the brain & heart & less to muscle
What is the thrift gene hypothesis?
One gene fosters survival in both feast & famine conditions, and as in modern society people only tend to suffer from “feast” conditions, so natural selection is reducing ability to reproduce in obese etc..
Why is over-nutrition associated with sub fertility?
females have higher levels of oestrogen, androgens & leptin which cause menstrual cycle irregularity, ovulatory failure & amenorrhea
What influence does obesity have on male hormones & the effects on fertility?
lower levels of testosterone, Increased oestrogen & leptin = reduce sperm production & increase erectile dysfunction’
How does periconceptional choline status affect health?
affects brain Development
How does periconceptional folic acid status affect health?
prevents first & second occurrence of neural tube defects; congenital malformations, preeclampsia, autism spectrum disorder, increased sperm count & viability
What is the main challenge regarding folic acid?
how do we increase awareness, knowledge & uptake?
What is the advice for folic consumption 4 weeks prepregnancy and 12 weeks peripregnancy?
800mcg
How do we make sure the population get enough folic acid prepregnancy if the pregnancy is unplanned?
Flour & rice & bread fortified but 2012 NZ withdrew programme)
What are the safety concerns regarding folic acid fortification?
folic acid fortification good for some, may cause harm, associated with reduced risk of colon cancer, cost?
How does periconceptional multivitamins status affect health?
Neural tube defects, congenital heart defect, urinary tract defect, limb reduction defect, preeclampsia
How does periconceptional zinc status affect health?
preterm birth; placental function
How does periconceptional omega-3 & B12 status affect health?
altered lipid metabolism
How does periconceptional iodine status affect health?
Neurocognitive
How does periconceptional iron status affect health?
iron deficiency anaemia, delayed development, preterm birth, infections & postpartum haemorrhage
What is associated with greater gestational weight gain?
High BMI
Low education
What % of women have excess weight gain during pregnancy?
74%
What is greater gestational weight gain associated with?
Higher risk of obesity
What is a healthy amount of gestational weight gain?
12-18 kilograms
How much does diet & exercise lower the risk of excess gestational weight gain?
20%
What do the Healthy eating for pregnant women guidelines show?
How many fruit, veges, grains, milk products etc… are required for healthy pregnancy
What are the pros & cons of using ginger for nausea & vomitting?
Pros:decreases both from 80-33%
Cons:
1. short term adverse effects; income outcome measurements & underpowered study
2. spotting may occur after 17 weeks of use
3. increases risk of haemorrhage
What are symptoms of hysteria monocytes?
Nausea, diarrhoea, achy muscles, fever (takes day to months)
What precaution should be taken to avoid developing hysteria monocytes?
Heat food above 70C; avoid ready to eat foods & unsafe foods (deli meats, fruit, veges, salads, soft cheeses & fish)
What is the % chance a baby will get hysteria through placenta?
100%
What is infertility?
failure to achieve pregnancy after 12 month of unprotected & routine sexual intercourse
What is the prevalence of infertility?
15%
What is the prevalence of infertility at 38?
26% women & 22% of men infertile
What are causes of infertility in men?
- Failed vasectomy removal
- Retrograde ejaculation
- Blocked ducts
- Absence of Vans deferent
- Undescended testes in childhood
6. Autoimmune disorders - Age: no. of sperm & quality decrease with age (increased risk of birth defects)
- Excess weight: reduced sperm quality
What are causes of infertility in women?
- Tubal problems
- Endometriosis
- Ovulation disorder z
- Polycystic ovaries
5. Recurrent miscarriage
6. Hormonal problems
7. Auto immune disorders
8. Biological clock (chance of pregnancy decreases from 25% to 5% by 42 & risk of miscarriage + abnormalities increases) 10% women experience menopause 5years earlier; 1% experience it 10years earlier - Excess weight: BMI > 35 reduces chances by 26-49%
What % of babies are born through assisted reproduction?
25%
How much does each cycle of IVF cost?
$20,000 +
How does smoking affect reproduction?
reduces no. & quality off eggs, reduce blood flow, also effect sperm production & quality, miscarriage more like, half chance of IVF working
How does caffeine affect reproduction?
CONTROVERSIAL but may reduce chances of pregnancy
How does alcohol affect chances of pregnancy?
impact foetal development; drugs: damaging to unborn babies; reduce chances of successful fertility
How do medications affect chances of pregnancy?
some interfere with fertility, aspirin may enhance fertility
What complementary theories may help with pregnancy?
aromatherapy, naturopathy, reflexology
How does stress effect reproduction?
infertility can be stressful; negatively affect ovulation, can take 29% longer to get pregnant
What are the benefits of following a Mediterranean diet?
+ improves insulin resistances
+ reduces metabolic disturbances
+ reduces obesity risk
+ decreases infertility
What is the composition of a Mediterranean diet?
minimise process foods, less red meat, move veggies, fruit, liquid oils, fish, beans/ legumes, nuts, seeds, poultry
What are some sources of calcium?
reduced fat dairy products (unsweetened) or fortified soy milk (most lactose intolerant cam eat yoghurt & cheese) also include broccoli, green veggies, almonds, chia seeds, dried fruit, beans & lentils & tinned fish
What is PCOS?
higher testosterone & insulin resistance leading to irregular ovulation & menstruation (stops release so eggs build up in ovaries)
What % of people does PCOS affect?
1 in 12
What % of people with PCOS are obese?
30-70%
What are the symptoms of PCOS?
irregular/infrequent periods; difficulty becoming pregnant; multiple cysts on ovaries, acne, excess hair, hair loss & thinning; overweight; mood changes, anxiety, depression, Increased risk of T2DM, high BP, CVD, fatigue & sleep apnoea
How are PCOS symptoms managed?
- Balanced diet
- active lifestyle
- maintaining health + weight
- minimise smoking & drinking
- manage symptoms with medication
- emotional wellbeing
- Myo-inositol (restore spontaneous ovarian activity)
What are the 9 stages of pregnancy?
- Conception
2 Fetal development (4 weeks) -> positive pregnancy test - Fetal development (8 weeks) -> eyelids limbs, fingers forming
4. Fetal development (12 weeks) 2.5 inch, starts to move & uterus starts to expand; can detect heart beat; can detect sexuality
5. Fetal development (16 weeks) increase growth, 4.3-4.6 weeks
6. Fetal development (20 weeks) -> feel them move
7. 24 weeks: well formed, can feel hiccups, inner ear fully formed so can feel upside down - 28 weeks: 2 pounds 6 ounces; changes position frequently, can survive
- 32 weeks: 4lbs; layers of fat starts to form;
What is an amniotic sac?
contains H20, Protein, CHO, lipids< phospholipids, urea and electrolytes to protect foetus from impact, infection, temp changes, dehydration
When does the amniotic sac develop?
2 weeks after conception
When is the amniotic sac the greatest?
34 weeks –> 800ml
When is the placenta formed (0.5kg)?
By 18 weeks
What is the role of the placenta?
Carries oxygen, nutrients to foetus & waste materials including CO2 from foetus to mother (placenta controls hormones)
How is the embryo connected to the placenta?
Umbilical cord
What is hCg (Human chorionic gonadotropin)?
stops menstrual cycle, stimulates the ovaries to produce oestrogen & progesterone
What hormone do pregnancy tests detect?
hCg
When is progesterone secreted during pregnancy?
Secreted by placenta after 12 weeks
What is the role of relaxin?
acts with progesterone to maintain pregnancy & relaxes pelvic ligaments at end of gestation
What does human placental lactogens promote?
Mammary gland growth
What nutrients travel into the placenta via passive diffusion?
important nutrients (O, CO2, fatty acids, fat-soluble vitamins, steroids, nucleosides)
What nutrients travel into the placenta via facilitated diffusion?
Sugars
What travels into the placenta via active transport?
amino acids, ca2+, Fe, Iodine, phosphate, water soluble vitamins
What is assessed during a placenta examination?
- Size, shape & completeness 2. Presence of accessory lobes, placenta infarcts, haemorrhage, tumours noduled 3. Measure umbilical cord & no. of vessels
What does a placenta examination show?
Shows how healthy pregnancy is
What is placental cultural rules?
In Western world most often incinerated; maori bury placenta to emphasis the connection between them & the earth
What are tetragens?
any agent that can disturb the development of an embryo or foetus; potentially causing a birth defect or halting pregnancy
What are 4 classes of tetragens?
- radiation
- maternal infections
- chemicals
- drugs
What % of adults have excess weight?
39%
What % of pacific, Maori, European & asian are overweight respectively?
63% pacific; 48% Mori; 29% European; 16% Asian
Why is maternal obesity a medical problem?
+ Manifest as metabolic/ reproductive complications
+ increases pregnancy risk
+ INCREASES COSTS
What are the 5 main implications of obesity on the mother?
- Pregnancy- induced hypertension: High BP, protein in urine & edema (toxemia or pre-clampsia)
- Increases risk of thromboembolism: blood clot in vein (can travel to heart or lungs)
- Delivery complications
- Increased obesity risk for offspring
Gestation diabetes mellitus - Increases risk of congenital abnormalities (birth defects)
What are congenital abnormalities?
CV defects, orofacial clefts (gap in palate/ lip), hydrocephalus (Cerebral fluid accumulated in brain
Why do congenital abnormalities occur?
Altered glucose metabolism, dieting or poor maternal diet
What percentile is classified as small for gestational age?
below the 10th percentile
What percentile is classified as large for gestational age?
above the 90th percentile or over 4kg
What is large for gestational age called?
macrosomia (increases risk of C-section delivery, fetal hypoglycaemia & shoulder dystocia (shoulder gets stuck behind pelvic bone (20% suffer injury – fractured clavicle, breathing, etc))
What are the odds of an obese women who gained excess weight during pregnancy having an overweight child (at 7years)
48%
What are possible mechanisms behind the association between gestational weight gain and overweight children?
Excessive GWG & hyperglycaemia overstimulates Beta cells leading to hyperinsulinemia (Growth hormone = higher BW) results in hyperphagia & weight gain
What does gut microbiome imbalance lead to?
diverse diseases such as allergic immune mediated diseases
What does a good gut microbiome lead to?
benefits immune system (provides defence against infections)
How do infants get a microbial inoculation?
After rupture of amniotic sac they receive microbial inoculation from delivery as there bacteria in placenta & stool in amniotic fluid
How should we build up the gut microbiome of children who got C-sections?
Innoculate with bacteria from mothers vagina
What are the 3 trimesters in weeks?
1st : 1-12 weeks
2nd : 13-28 weeks
3rd : 28 – birth
What is the survival chance 24 weeks?
50% survival chance
What are the short-term complications of pregnancy at 24 weeks?
- Respiratory distress syndrome
- heart: patent ductus arteriosus
- Brain: intraventricular haemorrhage
- GI: Necrotizing enterocolitis (inflammation of immature gut -> shuts down organs)
What are the long-term complications of pregnancy at 24 weeks?
Cognitive, vision, hearing, ADHD, anxiety, asthma, SIDS
What physical changes occur during pregnancy?
- 12-15Kgs are gained due to fat disposition
- growth of the reproductive organs & foetal tissues
- increased requirement for nutrients is given by foetal growth
- fat disposition
What hormonal changes occur during pregnancy?
- Progesterone & estrogen continue to rise & supress the menstrual cycle & this stimulates prolactin which helps mature mammary glands.
- Parathyroid hormone increases with pregnancy to build the skeleton of the baby (increases CA2+ uptake & reabsorption & stimulate osteoclasts)
- HCG (peaks around 10 weeks) from embryo itself
- Hormonal placental Lactogen: Produced by the placenta (decreases maternal insulin sensitivity & decrease mothers glucose use to help with fetal nutrition)
What can hormonal placental lalactogen cause?
Can lead to chronic hyperglycaemia & high blood glucose can lead to gestational diabetes
What metabolic changes occur during pregnancy?
- Maternal insulin resistance increase liver metabolism is also seen with increased glucogenesis to increase maternal glucose levels
- Renal plasma flow increases as does aldosterone & erythopieyen production
What cardiovascular changes occur during pregnancy?
- Cardiac Output increases 30% - 50%
- HR increases to 90 bpm
- BP drops in the 2nd trimester
Why does Blood pressure drop during pregnancy?
Due to increased Cardiac Output, renin & angiotensin
What risk does an increased heart rate during pregnancy pose?
risk of hypertension
What respiratory changes occur in pregnancy?
Increased tidal volume
Increased minute volume
Lower CO2
Why do respiratory changes occur in pregnancy?
Progesterone signals cause the brain to lower CO2
Uterus pushes on lung
What haematological changes occur during pregnancy?
BV increases by 40-50% (followed by RBC increase)
Why does blood volume increase during pregnancy?
Blood flow to uterus, metabolic needs of fetus & increased perfusion of other organs
Reduce the impact of maternal blood loss at delivery
What gastrointestinal changes occur during pregnancy?
- enlarged uterus pushes on GI tract & colon potentially causing constipation & decreased GI motility due to elevates progesterone levels (relax smooth muscles)
- Heart burn is common from delayed emptying
- HCL decreases (ulcers become less severe)
What is nausea & vomiting associated with?
HCG (from 5-18 weeks)
How do you manage nausea & vommiting during pregnanacy?
diet (eat slowly & small amounts ever 1-2 hours, avoid a full & empty stomach; protein-predominant snacks decrease nausea (ginger & B6)
How much weight gained during pregnancy is fluid, fat stores and the foetus?
3.2 kg fluid; 3.5kg fat stores; 3.5kg baby
How is gestational weight gain distributed?
1/3rd in 2nd ; 2/3 in 3rd trimester
What % of gestational weight gain is water, fat mass & lean mass respectively?
62% water
Fat mass: 30%
Lean mass: 8%
What does weight gain during the 1st & 2nd trimester reflect?
expansion of maternal tissue
What does weight gain during the 3rd trimester reflect?
Reflects primarily fetal growth, placental growth & accumulation of amniotic fluid
How much does accretion cost?
150 kcal/day
How much does basal energy expenditure increase?
100-180 kcal/day
How much does energy needs increase in each trimester?
1st trimester -> extra energy not required
2nd trimester -> 340 kcal day
3rd trimester -> 452 kcal day
Why are LCPUFAs essential during pregnancy?
They are essential for normal fetal development, particularly neural and visual function
- DHA is a critical component of cell membranes
- AA is a membrane component and a precursor to potent signalling molecules
How does Foetal LCPUFA accumulate during pregnancy?
n-3 fatty acid deposition occurs slowly then rapidly in the last trimester of pregnancy
What are dietary sources of omega 6?
+ Linoleic acid: soybean, vegetable oils, green veges, nuts & seeds
+ AA: Egg yolk, meats
+ GLA: evening primrose; black current oils
What are dietary sources of omega 3?
+ Alpha linolenic acid: soybean, canola, flaxseed & walnut oils, nuts & seeds
+ AA: Fish oils & oily fish
+ GLA: Fish oils & oily fish
Why do we need an equal ratio of omega 3 to omega 6?
Higher DHA = increased GA & heavier infants (high AA = opposite)
What concerns are associated with methyl mercury at low levels during pregnancy?
+ impact on LCFUs on child’s intelligence
+ Neurodevelopment consequences
What is the mean intake of DHA & EPA?
128 mg/day
What is DHA associated with?
Child cognition & visual acuity
How much DHA is recommended & what is the upper limit?
200-300 mg/day
UL: 3g/day
How much DHA is needed during pregnancy?
+ development potential is unknown currently on individual level
+ enhanced DNA is not expected have a benefit over their need
+ functional measure shows amount for optimal brain development
How much iron is needed to meet pregnancy demands?
1000mg
Why are iron needs increased during pregnancy?
to create more blood for mother & baby’s increased BV & blood loss at birth
How much is iron absorption enhanced during pregnancy?
from 1.2 mg/day to 5.6 mg/day
How much iron does a pregnant women need to consume compared to a not pregnant women?
27 mg/day from 21 mg/day
What does a 60mg iron supplementation help with?
Low birth weight
When should iron be screened?
First booking & 28 weeks
What Hb concentration suggests that oral iron supplementation is urgent?
<100
What are the side effects of iron medications?
nausea, vomiting, constipation, diarrhea
Why should we give iron tablets to iron replete women?
Increases the chance of gestational diabetes
Why is it important that babies have built up large iron stores?
Breast milk has very low iron
What are 3 interventions for low iron?
- Fortifying staple foods
- Deworming
- Improve sanitation
What risk does iron depletion pose?
Increases risk of cardiac failure or death from peripartum hemorrhage
What is iodine essential for?
For the production of thyroid hormones
What are the roles of thyroid hormones?
- regulating the body’s metabolism
- Normal growth
- neurocognitive development of fetus, infant and child
What is severe iron deficiency during pregnancy associated with??
maternal and foetal hypothyroidism (congenital anomalies, decreased intelligence, and cretinism (physical deformity + learning difficulties) as well as maternal and foetal goitre)
What is mild maternal iodine deficiency associated with?
mild maternal thyroid hypofunction and decreased child cognition
Why are pregnant women more susceptible to iron deficiency?
Much higher requirements:
EAR 160 mcg/d, RDA 220 mcg/d
What are foetal levels of alcohol compared to maternal levels?
The same
What withdrawal symptoms may infants expose to alcohol in utero experience?
hyperactivity, excessive crying, irritability, weak sucking, disturbed sleep, hyperphagia, seizures
What are the main features of metal alcohol syndrome?
- Growth deficiency of prenatal onset
- CNS dysfunction (microcephaly, delayed development, hyperactivity, attention deficits, learning disabilities, intellectual; deficits)
- specific pattern of facial characteristics (short palpebral fissures, thin upper lip; smooth/ long philtrum)
What are the 3 components of fetal alcohol disorder spectrum?ohol related
- Full FAS occurs with regular heavy alcohol intake or very high alcohol concentrations
- Alcohol related neurodevelopment disorder (difficulties with math, memory, attention, school, impulse control & judgement)
- Alcohol related birth defects (issues with heart, kidneys, bones & hearing)
What nutrients are most at risk of inadequacy with alcohol consumption in pregnancy?
- folate
- vitamin A
- Vitamin C
- thiamin
- calcium
- iron
- fibre
What % of women consumed alcohol during pregnancy & what & are binge drinkers?
30-40%
10-12%
What is heavy episodic drinking defined as?
Defined as consuming > 4 standard drinks on one occasion
What is heavy episodic drinking in early pregnancy associated with?
preterm birth; lower BW; craniofacial defects; sudden infant death syndrome; sleeping problems and difficult temperament; adolescent antisocial behaviour, school problems and self- perceived learning difficulties
When did prepreganncy health labels become mandatory?
July 2020
What is gestational diabetes defined as?
any degree of glucose intolerance with onset or first recognition during pregnancy
What is hyperglycaemia associated with?
An increase in the risk of intrauterine fetal death during the last 4–8 weeks of gestation
What does gestational diabetes mellitus associated with?
Fetal macrosomia
What are long term complications of gestational diabetes in the mother?
Increased risk of type 2 diabetes (enhanced by obesity & other factors that promote insulin)
What are long term complications of gestational diabetes in the offspring?
At increased risk of obesity, glucose intolerance, and diabetes in late adolescence and young adulthood.
What are risk factors for gestational diabetes?
\+ 35 years+ \+ family history \+ previous history previous large baby \+ excess weight \+ PCOS
When should pregnant women be screened for gestational diabetes
- before 20 weeks (HbA1c > 50 = diabetes)
2. 24-28 weeks (75g oral test is HbA1c = 41-49 mol/mo or 50g if <40l)
What glucose concentration requires further testing and immediate refer during 28 week screening?
>11.1 = immediate referral 7.8-11 = two hour OGTT
How should gestational diabetes be managed?
- receive nutritional counselling (adequate nutrition)
- ultrasounds to assess fetal growth
- metformin + insulin might be required
4.
What are the issue with carbohydrate restriction proposed for gestational diabetes?
- higher fat intake
2. excaberates maternal insulin resistance
Why do we reduce fat intake to 30-40% of calories?
To limit postprandial hyperglycaemia = decreases fatal glucose exposure & lessens the risk for macrosomia
What follow up should be taken for gestational diabetes?
- informed about risks of developing type 2 diabetes or gestational diabetes in future pregnancies
- HbA1c 3 months postpartum & annually (unless = 41-49 then annual)
What are alveoli?
functional units of the mammary gland
What is each alveolus composed of?
cluster of secretory cells) with a duct in the centre to secrete milk arranged like branches of a tree with each smaller duct leading to 6-10 larger collecting ducts leading to nipple
These are surrounded by my-epithelial cells
What is the role of my-epithelial cells in lactation?
contract under influence of oxytocin and cause milk to be ejected into ducts
How many lobes is a mammary gland made up of?
15-25
How many lobules is a lobe of a mammary gland made up of?
20-40
What allows oxytocin to reach alveoli?
Good vascularisation
When do ovaries mature & increase in oestrogen & progesterone?
12-18 months after menarche
How do the mammary glands develop during puberty?
- ductal system matures
- nipples grow & pigmentation change
- fibrous & fatty tissue increase around the duct
How do the maaary glands develop during pregnancy?
- Human chorionic gonadotropin and placenta lactogens help preparation
- oestrogen stimulates gland development
- progesterone elongates the tubules & duplicates epithelial cells
What are the two lactation hormones?
- Prolactin: Stimulates milk production
2. Oxytoxin: stimulates ejection of milk from glands into ducks (letdown)
Why does oxytoxin act in uterus during & after delivery?
causing it to contract, seal blood vessels and shrink in size
What are the 3 stages of lactogenesis?
- Lactogenesis 1: last trimester to few days postpartum
- Lactogenesis 1: 2-5d postpartum (increases in volume/ changes composition)
- Lactogenesis 3: 10 days postpartum: stable milk composition
What is colostrum?
Concentrated milk in lactogenesis 1 containing: \+ Lymphocytes \+ IgA, IgM, IgM \+ High protein (low fat) \+ Vitamins & minerals
When is breast feeding first initiated?
Within the first hour of birth
What reflexes are healthy infants born with to help them feed?
- Suck & swallow (gag reflex)
- Oral search reflex
- Rooting reflex
What is the oral search reflex?
Open mouth wide in proximity to breast & thrusting tongue forward
What is the rooting reflex?
Turns head when lip is stimulated
What are the mechanics of breastfeeding (steps)?
- suction elengates nipple & areola
- baby compresses areola (milk travels down ducts)
- baby carries out peristaltic motions forming a grove in the tongue to carry milk to throat
- Receptors initiate swallowing
What are some ways to help establish breastfeeding
- Skin-to-skin contact
- Staying hydrated
- Responsive feeding
- Emptying breasts – removal signals production
What is typical milk production?
1st month:600 ml
4-5 month: 750-800 ml
What are the 10 components of milk?
- water
- Protein
- Carbs/ lactose
- fats
- antibodies
- vitamins & minerals
- oligosaccharides
- bacteria
- immune cells
- hormones
Why don’t baby need water?
Breastmilk is 88% water
How much energy is in breastmilk?
0.65-0.7 kcal/ml
What is the macronutrient composition of milk?
- Fat is low in fore milk & high in hind milk (provide half the energy & cholesterol)
- protein content = low
- Carbohydrates: lactose enhance calcium absorption (also glucose & gut bacteria)
What are human milk oligosaccharides?
Complex, indigestible, medium-length CHO with lactose on one end that act as a prebiotic to Stimulate growth of Bifidus bacteria and inhibits Escherichia coli
to Prevent binding of pathogenic microorganisms to the surface receptors of their target cell
What vitamins & minerals are not sufficient in human milk?
- B-vitamins if maternal intake is low
- Vitamin D
- Iron – low but high bioavailability
What is the average iron consumption of human milk?
0.35 mg/L
Why is iron in breastmilk more bioavailable?
- Lower Ca
- Lower Phosphorus
- Lower protein
- high concentration of action
- high concentration of iron-binding protein
- High lactoferrin
How much iron is absorbed in BM compared to infant formulas?
50% vs 10%
What is lactoferrin?
Globular glycoprotein of the transferrin family
What is the role of lactoferrin?
- Mediates iron absorption via a lactoferrin receptor `
- Withhold iron from pathogens
- regulate cell growth
- activate DNA sequences
- NK activation
- anti-tumour activity
- help digest viral DNA
- lactoferricins have antimicrobial, antiviral, anti tumour & immunological function
What is a major determinant of anaemia risk during infancy?
Infants iron reserves at birth
What is sustained iron deficiency anaemia associated with in infants?
- irreversible and detrimental effects on intellectual and motor performance
- restricted linear growth
How much vitamin D is available in breast milk compared to formula?
20-70 IU/L
vs
200 IU/L
How can we increase the vitamin D content of breastmilk?
Mother must consume a high dose supplest of vitamin D (1% of what consumed in breastmilk)
What Supplementation of vitamin D is recommended in different countries?
France/ Finland = 100 UI
Canada, U.S, U.K.: 400 IU
NZ: no policy
what are the risk factors for vitamin d deficiency?
- Naturally dark skin
- Sibling diagnosed with rickets
or hypocalcaemic seizures - Mother who is deficient in vitamin D or is at higher risk of becoming deficient
- All preterm infants < 2.5 kg
- Infants BF over winter months
How can vitamin D be administered to baby?
- directly to Childs mouth
- added to food/ drink
- on nipple
What is world breastfeeding week?
Campaign to
- inform people about importance of BF
- Anchor BF support at public health responsibility
- Engage with individuals & organisations
- excite action on protecting BF
What are the WHO recommendations for BF?
- Infants should be exclusively BF in the first 6 months
2. complementary food past 6 months
What does exclusive Breastfeeding protect against?
- Diarrhoea
- Respiratory illness
- Decreased Breast cancer risk
- Increased in IQ in child
- Decreased childhood obesity
What are the three primary benefits of exclusive BF for the mother?
- prolongs the duration of lactational amenorrhea
- Accelerates weight loss
- Lowers the risk of breast cancer
What are the two primary benefits of exclusive BF for the child?
- Protective against gastrointestinal infections
2. Potential enhanced motor development
What is the challenge of exclusive BF?
- 38% infants exclusively breastfeed (rates have stopped declining)
- formula-fed in unhygienic conditions 6-25X more likely to die from disease
- 25% increase in mortality in formula fed
What are the main reasons mothers do not breast fed
- Returning to work
- social perception
- lack of knowledge about expressing & storing
- factors associated with obesity
Why are obese women less likely to breast fed?
- have lower milk production 2. greater latch difficulties
- High rate of ‘medicalized’ pregnancy and childbirth
- Perceived insufficiency of milk supply
- Body image issues with feeding in public = early cessation
What is the international baby friendly hospital initiative?
All maternities become centres of BF supporting by:
- does not accept free breast milk substitutes
- feeding bottles or treats
- implanted 10 steps to support BF
What are the 10 steps to successful BF?
- written/ communicated BF policy
- Train staff to implement policy
- Inform pregnant women about benefits & management of BF
- Help mothers initiate BF within 30min
- Show mothers had to BF
- no food/drink for first 6m
- allow mothers & infants to remain together
- encourage BF on demand
- No artificial teats or pacifiers
- Foster the establishment of BF support groups
What are some BF challenges?
- Baby won’t BF
- Sore & cracked nipple
- engorgement/ breast fulls
- Mastitis
- Baby biting breast
- Low milk supply
- Blocked milk ducts
- Babies with tongue-tie
What are issues with preparation?
- flat/ Inverted nipple (pumping elongates; nipple shields)
- Breast Surgery
- no issues with breast size (larger needs less frequent feeds)
How does alcohol affect Breast feeding?
+ It inhibits release
+ affects milk production & infants sleeping/ eating patterns
+ affects brain development
How long does it take a women to get rid of the alcohol from 1 standard drink?
2 hours on average
What are the 3 types of infant formula?
- Infant formula (0-12m)
- Follow-on formula (6-12m)
- Formula for dietary use
How is infant formula regulated?
- Codex reviews evidence to set mins & maxes
- Must comply 2.91 (composition & safety requirements)
- Mandatory nutrient content
- labelling requirements
- controls additives
What is home made infant formula made up of?
Liver, cod liver oil, bone broth
What is the issue with homemade infant formula?
Bad for immature kidneys
Bad for GI tract
Microbiological risk
What is the casein: whey ratio of breast milk, whey dominant formula & casein dominant formula?
BM: 40:60
Whey dominant: 40:60
caesin dominant: 80:20
Both BM & whey dominant formula have a casein: whey ratio of 40:60; what is the difference?
Whey protein is alpha in BM; Beta in Cows
Caesin protein is Beta in BM & goat; alpha in cows
How much protein does BM & infant formula have per 100kcal, respectively?
BM: 1.5g/100kcal
Formula: 2.2g/100kcal
What is the early protein hypothesis?
More protein = more circulating amino acids and greater insulin & growth factor secretion (IGF-1 which are anabolic
What is a higher protein intake during infancy associated with?
- Greater weight
- Increased risk of obesity
- High weight persisted during school
What is minimum protein requirement for formula?
0.38 g /100 kJ (proposed to be 0.45)
What is the main carbohydrate in breast milk?
Lactose
What does lactase enzyme deficiency cause?
diarrhoea, cramps, bloating, vomiting, gas
What carbohydrate do lactose free formula’s typically use?
Corn syrup, sucrose or fructose
What fat ratio in milk affects it digestibility?
Ratio of PUFA to saturated fat
What type of fat must infant formula contain
Linoleic acid
Alpha-linolenic acid
What type of fat is assed to formula at a cost?
LCPUFS
What is the max % of trans fatty acids in infant formula?
3%
What is taurine associated with/ why is added to formula?
Associated with Neuro- & Retinal development
What is chloride associated with/ why is it added to formula?
To prevent hypochloremic alkalosis (associated with cognitive delays, language disorders, impaired/ visual motor skills)
What are the minimum & maximum quantities of chloride in infant formula?
- Minimum 55 to 65 mg/100 kcal
2. Maximum of 150 mg/100 kcal
Starter formula is ____ based; Follow on formula is ______ based.
Whey
Caesin
What are the 4 major categories of infants formulas?
- Cows milk
(hydrolysed used if intolerant to enact proteins or lactose free if lactose intolerant) - Soy: if lactose intolerant or have galactosemia
- Goat: cultural reasons
- Specialised ( preterm, GI reflux, inborn errors of metabolism)
What benefits are proposed by adding prebiotics, probiotics, nucleotides & oligosaccharides to formula?
- Prebiotic: Help gut macrobiotic (weak evidence) Greater impact on pre-term
- Probiotics: Beneficial live microorganisms
- Nucleotides: GI tract & immunity
What is the issue with specialised ingredients in infant formula?
Lack of regulatory codes & health claims
What is the difference between teats for older and younger children?
Teats for older children have multiple & faster flow
How do we administer infant formula?
- sterilise bottles & teat
- warming is not necessary (don’t heat in microwave!)
- use within 2h
How frequently should infants be feed formula
6-8 times a day
What shows readiness to feed?
- can reach for spoon
- clenches fist
- Moves tongue side to side
- support head & body upright
5, reach for stuff while sitting upright
Motor development occurs top down and _____ to ______ (proximodistally)
centrally; peripherally
When do first teeth erupt & when do infants have a full set?
Between 6 & 9 weeks (full set by 3 years)
What are the 5 developmental stages of feeding?
- 6 months: suck, swallow, extrusion reflex & move liquid
- 6-7 months: side to side movements (manipulate)
- 7-8 months: can eat thick/puree & mashed lumps
- 8-12 months: Chew & swallow soft, mashed, minced, grated, chopped foods
- 12-24 months: consumes 3meals & 2 snack
How does calorie intake and feeding frequency change over infancy?
6-7 months: 200 kcal/ day 2-3x day
(milks given before food)
8-12 months: 3 x a day with one nutritious snack ~ 686 kcal/day
12-24 months: 12-24 months: 3 meals + 2 snacks (~890 kcal/day)
What are some of the first foods that can be introduced during complementary feeding?
- Cooked & pureed fruit & veges
- Uncooked mashed banana & avocado, carrots etc..
- Cooked & pureed vegetarian alternatives: 4. hummus, baked beans, lentils, soaked/ cooked/ dried beans/ peas
What is responsive feeding?
Listen to babies hunger & stately cues
Parent chooses when & what
How many times do you need to expose infant to a new food before they accept it?
8-15 times
What shouldn’t be added to home prepared infant food?
fat, salt, sugar & honey
What liquids should be avoided in infancy?
No juice, soft drinks, tea (including herbal tea)
What factors affect food acceptance?
- taste + smell (prefer sweat; reject bitter)
- tactile stimulation + texture
- visual appearance
How do we promote better acceptance of new foods?
Introduced to a variety of foods frequently (large range of tastes + textures)
when does sucking become under voluntary control?
4 months
At what age do babies begin chewing?
6 months
When is the sensitive period of introduction of lumpy foods?
before 10 months (otherwise difficulties at 15 months)
how often should meat, poultry, fish & eggs should be eaten?
daily
What is neophobia?
reluctance to try new foods
What is baby led-weaning?
- Give softened family foods from 6 months
What demographic is likely to use baby-led weaning?
Higher income; higher educated mums
What are the issues and advantages of baby led weaning?
Issues:
- A lot of food waste
- concern if getting enough nutrients
- more risk of nutritional inadequacies
advantages:
Helps with exposure, motor skills 7 acceptance
What age is it acceptable to give cows milk to an infant & why not earlier?
Acceptable after 1 year old
- The high protein content may cause gastrointestinal blood low
- low iron & bioavailability
What is the max amount of milk that should be given to an infant & why?
low iron and it fills baby up (includes BM)
What is the international code of marketing breast-milk substitutes?
Marketing of substitutes is restricted to prevent discouraging BF
What makes up the international code of marketing breast-milk substitutes?
- forbids advertisement/ marketing
- forbids claiming health benefits
- forbids contact between representatives and medical personal/mothers
- no distribution of free samples in hospitals & public health services
- baby food adverts may not target under 6 months
- no promotional distribution of pacifiers/ bottles
- manufactures may not distribute promotional gifts
- can’t put images of mother/ children on labelling
- Labels must state BF is best
In New Zealand international code of marketing breast-milk substitutes mandatory?
Not voluntary, self-regulatory
What is the international baby food action network?
Monitors baby food marketing in 69 countries
What does atopic disease include?
includes food allergies, atopic dermatitis, asthma
What does atopic disease in infants & children cause to be produced?
Produce IgE antibodies after exposure to allergens (occurs when the immune system is dysregulated)
when do children with asthma typically develop symptoms?
- By 6 years
2. 1/3 of children who develop wheezing before 3
What are food allergies?
immunologically mediated hypersensitivity reaction to any food
What are the 2 types of food allergies?
- IgE mediated
2. adverse non Ige immune reactions
How long may the response be of immune related non-mediated food allergies?
Up to 2 days
What is Atopic dermatitis (eczema)?
a chronic inflammatory skin disease
What is the first atopic disease to manifest; what may it progress too?
Eczema progresses to asthma or rhino conjunctivitis
What is Eosinophilic Oesophagitis?
inflammation in a part of the GI system
What are the symptoms of an Immune related non-mediated IgE food allergies?
+ upset stomach (difficulting swallowing, vomiting, diarrhoea)
+ may lead to poor nutrient absorption; failure to thrive
How do you diagnosis Immune related non-mediated IgE food allergies?
has to use elimination/ re-introduction diet
what are symptoms of a food allergy?
tingling/ itching of mouth; itchy red rash, swelling, wheezing, sick, vomiting, shortness of breath, abdominal pain,
What is coeliac disease?
Immune system produces antibodies which inflames & damages the lining of the small intestinal tract as a reaction to gluten
stopping nutrient absorption
What are food intolerances?
immediate & delayed adverse reaction to foods that does not involve the immune system
What are some symptoms of food intolerances?
diarrhea, nausea, cramping & headache
How many reported food allergies are there?
160
What are the 6 most common allergies?
- Cows milk & egg white 3%
- Peanut: 0.8%
- Tree nuts (almonds, brazil nuts, cashew…) 0.2%
- Soy: 2%
- Wheat: common allergy in
- childhood but usually resolves
What is the most common allergen for infants & how many outgrow?
Cows milk & egg white
70% outgrow
What % of infants that react to Cows milk & egg white also react to goat & soy respectively?
92% also react to goat
17-47% also react to soy
When performing a skin prick risk what size wheel diameter indicate an allergy?
3mm
What % of children & adults experience atopic disease?
6-8% children; 2-4% adults
How has atopic disease prevalence changed over the last 2 decades?
- Asthma has increased 160% (NZ 2nd highest rate in world)
- Atopic dermatitis has increased 2 to 3 fold
- peanut allergy doubled due to avoidance of common allergens
What are the causes of atopic disease?
+ genetic link
+ environmental factors (migration differences; environment = important determinant -> window of opportunity)
What contributes to the development of allergies during utero?
- Adverse life effects
- smoking
- air pollution
- medicines
- microbial farm environments
- c-section
- winter babies
Do dietary restrictions prevent allergy development during pregnancy?
No
What helps prevent atopic disease?
Exclusive Breast feeding
What is the evidence to date on the role of human milk on atopic disease?
no RCT
no evidence that should avoid anything (advantageous to expose!)
If an infant is at a high risk for atopic disease and not able to breastfed, what should we feed the the infant?
Feed high-risk infants, a protein- hydrolysed formula to lower risk of developing eczema and cows milk allergy
How do allergies affect quality of life?
They are hard to avoid, can cause activity avoidance & bullying
How is the food environment managed for allergens
- Infor must be accurate
- Allergens must be listed (bolded)
- Contain statements
- May contain statements (cross-contamination)
- needs to be able to provide info on request
What is the food allergen portal?
resources & training protocols to set up establishments properly
How much has food allergy rates risen?
Increased prevalence by 50% (peanut allergy tripled)
Why have food allergy rates risen?
- avoidance common allergen foods
- Vitamin D (no evidence)
- hygiene hypothesis: reduced exposure to infectious diseases & microbial products has reduced immune deviation along with increased antibiotics
What is the evidence behind the hygiene hypothesis?
- countries who didn’t avoid allergen containing foods had less allergies
- Dual allergen exposure:
Skin exposure can cause allergic reaction if haven’t developed oral exposure tolerance - exclusion for 1y = 74x more likely to develop allergy
What shows there its a time & dose effect of early allergen introduction?
67% lower relative risk of food allergy overall in early intro group
What are 6 steps to prevent allergy & atopic disease?
+ exclusive BF for at least 4 months
+ delayed introduction of complementary foods
+ sustaining exposure
+ get things with gluten before 7 months (BM provides immunological umbrella)
How much does birth weight increase in the first 4 months?
Doubles
How much does birth length increase by 12 months?
1.5x
How much does head circumference increase in the first year (cm)?
~11cm
What is the Apgar scoring system?
A system that scores infants on 0, 1 & 2 for muscle tone, pulse, grimace (reflex irritability), appearance (skin colour) & respiration
What are average birth weight & birth length?
3290g & 50cm
What measurement should not be taken at birth?
Head circumference
What is the role of a child growth assessment & how is it performed?
Role: Determining if a child is growing normally or has growth abnormalities
How: Compare measurements to age standards/ references and monitor growth velocity
______ is a good indicator of acute changes
______ reflects long-term nutrition
________ reflects brain growth
Weight
Height
Head circumference
When is increase in head circumference reflective of brain growth until?
1 year
How do we measure infant weight?
- Remove clothing + nappy up to 2 years
2. Children 2y + minimal clothing, remove shoes & empty bladder; before a meal
What do we record weight too?
Nearest 10g
How do we measure infant length?
- Use calibrated length board with fixed headboard & moveable foot piece
- Straighten out legs, placed on back, toes should be pointing (length to nearest 0.1cm)
- take average of 3 measurement
++ use 2/ 3 trained people
How do you measure an infant’s head circumference?
flexible, non-stretchable tape above the ears and around the biggest part of the back of the head
(take average of 3 measurements)
Where do you take mid upper arm circumference?
measured over the left upper arm, at a point marked midway between the acromion (shoulder) and olecranon (elbow) with arm at right angle
What are some normative growth references?
- Tanner growth charts (effected by wartime malnutrition) -> accounting for variations in child’s tempo of growth (1960)
- US National Center Health Statistics (only measured every 3 months) (1977)
- NZ Growth Charts (Maori & pacific were underrepresented; not optimal growth; inc. BF & FF)
- WHO funded child growth standards
What was the goal of WHO funded child growth standards?
Provide a single international standard that represents the best description of physiological growth for children up to 5 years (breastfed only as normative)
What type of studies was the WHO funded child growth standards made from?
- Longitudinal from birth to 2 years
2. cross-sectional data from 18 months to 6 years
What were the conditions to be included in WHO child growth standards ?
- Favourable SES
- EBF for at least 4 months in longitudinal
- Complementary food introduced at 6 month
- BF to 12 months
- No maternal smoking
- LBW included
What was measure in the development of the WHO child growth standards ?
Developmental milestones measure and anthropometrics
How often were Developmental milestones measure and anthropometrics measured in the WHO child growth standards ?
- fortnightly to 2 months
- 1 month to 13 months
- 2 months till 2 years
What are the innovative aspects of the WHO child growth standards ?
+ prescriptive approach
+ Breastfed is normative model
+ international sample
+ reference data for assessing childhood obesity
What growth standards have been produced?
- weight for growth
- length/height for age
- weight for length/ height
- BMI for age
- MUACF for age
- skinfolds for age
- Head circumference for age
What is the variation in growth curves of individuals compared to groups?
70% vs 3% (No difference between ethnicities)
What growth standard should be used before 10, and after respectively?
Weight for Age
BMI
What % full between +1 & -1; 2SD & what % fall between -2 and +2?
67%
95%
How do we interpret height-for-age Z scores?
Below -2 = stunte Below -3 severly stunted \+3 flags endocrine disorder \+2 overweight \+3 obese -2 wasted -3 severly wasted
What is oedema?
Fluid collection in tissue due to malnutrition?
What clinical assessment is used to diagnose oedema?
Apply pressure with thumb for 3 seconds – if
dent is seen or felt then oedema is present
What was the second object of the WHO child growth standards ?
to assess motor milestones relevant to age and sex, and in contrast to physical growth
What has the WHO child growth standards show about motor milestones?
+ no difference between healthy kids of different sizes
+ undernourished children will experience delays
+ age variation high
+ dependant on opportunity, genetic & cultural differences
What Growth charts does NZ use?
WHO growth Charts
+ 9 percentiles from 0.4 to 99.6
+ starts at 2 weeks (babies lose weight first)
Babies typically lose weight in the first two weeks due to the low volume of colostrum, when should the parent worry?
Above 10% weight loss or producing less than 7 wet nappies daily
What are plunket milestones?
Milestones that represent what children can do at a certain age in terms of movement, hearing, sight & communications (correct & prevent delays in development)
What is the issue without incorrect length at birth?
- looks like in utero growth & postnatal growth faltering
2. Can impact management (receive unnecessary treatments which can impact BF)
What age do we stop measuring head circumference?
1 year
When should we measure infants?
Within 1/2 weeks 1,2,4,6,9,12,18,24 months
What percentile is classified as overweight & very overweight?
91
98
When do we observe a shift in percentile line & why?
2 years because measurement method changes
What does a Drop or rise in head circumference indicate?
Problems such as Cerebral spinal fluid in brain
When should BMI be used?
- Above the 99.6th centile on weight chart
- Below the 0.4th centile on weight chart
- OR if their growth crosses two percentile spaces downward
