Perinatal Nutrition

See also Perinatal Nutrition

Largely from an article by S A Udipi, P Ghugre and Usha Antony at http://www.jimaonline.org/sep2k/print_special2.html

Maternal nutrition not only affects  pregnancy, but also affects health of the child  in later life by metabolic imprinting in utero. There are  critical periods in development particularly in foetal development that must be successfully completed at the correct time otherwise  irreparable damage to the child and the course of development may be irreversibly  altered,

Evidence  indicates that perinatal nutrition has a definite and lasting effect on a child's  growth, immunity, brain development and leaning ability. Evidence also indicates that poor perinatal nutrition can lead  to adult obesity, cardiovascular disease, hypertension and maturity onset diabetes.

The infants heath is also dependent on the mother post-pregnancy. Lactation  effects the health and nutritional status of the neonate through  further stages.

 The  demands during  these critical stages of the lifestyle, are very high  and must be met by an increase in food intake by the mother.

There are energy-sparing adaptations that  reduce the maintenance requirements of the mother and make  energy  available to the foetal  or for lactation. however maternal reserves will  be utilized if the diet is inadequate in both pregnancy and lactation.
The infant is protected during human lactation even  in  acute calorie deficiency because the energy content  of breast milk is maintained at the expense of the mothers. This means that if the mothers diet is inadequate, the mother's own nutritional status  suffers.
With marginal nutrition, lactating women, have an energy-sparing suppression of basal metabolic rate. In populations where food intake is restricted or  women cannot afford to decrease physical activity, energy-sparing adaptations and fat mobilization  play an important role in maintaining energy balance of the lactating mother.

Throughout pregnancy and lactation there is a continuing adjustment of maternal body composition, metabolism and  physiology . A diet that meets maternal nutritional needs is required to ensure maternal well-being and the birth of an healthy infant.

Breasted for the first 4-6 months   improves infant survival . During this period, maternal nutritional  can improve the  health of both mother and  infant. Not all nutrients are distributed between the mother and child in the same way:

1) some nutrients, the infant  is maintained at the expense of the mother,
2) other nutrients, mother and infant compete more evenly
3) and for others the infant suffers greater  deficiency than the mother.

1)  nutritional status before pregnancy
2)  nutrient intake and utilization during gestation.
3)  age,
4) genetic factors,
5) socio-economic, cultural and educational factors.

Foetal stage:
Nutritional demands are high as the growth rate is highest at the foetal stage compared to any other time in life.

Influence on birth weight:
Maternal influence on birth weight is stronger than the paternal one.

• Birth weights among half siblings showed a significantly high correlation  when they had the same mothers than fathers.

•   the intra-uterine environment (62%),
•   maternal genes (20%)
•    foetal genes (18%).

The growth of the foetus is influenced both by

•  genes
•  availability of nutrients
•  availability oxygen.

•     maternal body composition and size,
•     maternal nutrient stores,
•     maternal food intake,
•     transport of nutrients to the placenta,
•     transfer across the placenta.

Optimal pregnancy performance also depends on:

•   protection from all preventable diseases (e.g., German measles),
•   tight control of all chronic and metabolic disorders (e.g., diabetes mellitus),
•   eradication of all habits harmful to the mother (e.g., tobacco, alcohol),
•   early and frequent prenatal care.

Growth of both maternal and foetal tissues:

Adequate nutrition supports the major maternal alterations affecting every  organ system . The two main physiologic forces driving these changes are

•     a 50% expansion of plasma volume with
•     a 20% increase in haemoglobin mass.

Maternal weight gain depends on the pre-pregnant weight and should be be gradual during the second and third trimesters
 

Obligatory weight gain

The foetus, placenta, amniotic fluid, uterine and breast tissue and blood volume is about 7.5 kg
 Average weight gain is about 11.5 kg, 25% of which is due to the foetus.

 Recommended the weight gain for pregnant women is based on their body mass index (BMI)
(Table 2) underweight women being expected to gain more weight than  overweight women.
 

Under nutrition in pregnancy
Effects of under nutrition in pregnancy depend on the stage as well as severity.
Chronic under nutrition throughout pregnancy  affect birth weight.
The high prevalence of low birth weight babies ( <2.5 kg)  in turn increases  infant mortality.
Maternal nutrition is one of the major determinants of intra-uterine growth retardation (IUGR) .
Low prepregnancy weight and low weight gain during pregnancy combined cause high incidence of  low birth weight .

Maternal kj. intake during pregnancy has no effect on prematurity however supplementation has a positive effect on birth weight and IUGR, the beneficial effect is greater for malnourished mothers.

• For malnourished mothers an additional 100 kcal ingested daily throughout pregnancy will increase the birth weight by about 100 g, as compared to a 35 g increase in birth weight of infants born to non-malnourished mothers.

Nausea and vomiting are common complaints in pregnancy, occurring in more than
50% of pregnant women. Occasionally, the vomiting becomes severe and persistent
enough to develop into the syndrome called hyperemesis gravidarum and sometimes
requires hospitalization.
The severe vomiting is associated with an  inability to eat or drink and affects 1 in 300 pregnant women in Australia
Treatment involves trying to find a food and drink that can be kept down. Sometimes dry biscuits and sports drinks are accepted but a patients tolerance changes day to day.
Choice of food to help avoid nausea & vomiting is discussed by  Dietetics team at the Chelsea
and Westminster Hospital in London
Drug treatment may be needed and the drug of choice is  maxalon This drug can have side effects or not be strong enough. Unfortunately there are not many alternative drugs that are safe during pregnancy. One very effective drug was thalidomide but that caused very severe terotgenic effects on the foetus
If maxalon has side effects then prednisolone a corticosteroid can be prescribed it has different side effects and withdrawal symptoms
Ondansetron is a 5-hydroxytryptamine receptor antagonist which is known to be a highly
effective anti-emetic drug for chemotherapy-associated nausea and vomiting and for
postoperative nausea and atchieves rapid relieve of hypermesis. however the drug is not yet thoroughly tested for safety with pregnancy. Animal studies have shown that
maternal corticosteroid delays myelination and reduces the growth of all foetal brain

There is some evidence that sever hyperemesis gravidarum is associated with the bacteria that has also been connected with gastric ulcers i.e. Helicobacter pylori these cases were resolved with antibiotic treatment using erythromycin.
 

Effects growth after birth of maternal malnutrition during pregnancy

Maternal nutrition during pregnancy influenced growth of the offspring beyond the intra-uterine period.  In one study birth weight and length of  children of supplemented mothers were significantly heavier up to the age of 24 months and taller through the first 5 years than unsupplemented mothers.

It is  recommended that mothers take an additional intake of 300 kcal/day during the second and third trimesters of pregnancy.

 Effects of anaemia on the mother :
The high prevalence of iron deficiency anaemia up to  70% among women is  contributory to maternal mortality, undernutrition of the foetus and infant mortality.  there are  negative effects on both the mother and the infant.

• The mother is at greater risk of death during the perinatal period. Anaemia is the major contributory or sole cause in 20-40% of such deaths.
• Performance during pregnancy and delivery
  • (a) Shorter pregnancies in anaemic women,
  • (b) inadequate gestation weight gain,
  • (c) the more severe the anaemia, the greater the risk of LBW,
  • (e) poor delivery performance and more complications during delivery.
• In severe anaemia, cardiac failure during labour is a major cause of death.

• Higher rates of foetal deaths and abnormalities, premature deaths and LBW new-borns, even among mothers who had anaemia, only in the first half of pregnancy.
• Alterations in brain function that may result in poor mother-child interactions and impaired schooling later.
• Foetal iron deficiency

• Deficiencies of as zinc, iodine and folate have  specific adverse effects on the development of the foetus.
  •  growth retardation
  •  development
  •  immunity

The maximum daily need for protein occurs in the final weeks of pregnancy.
On the basis of N need for foetal growth and extra of maternal tissue it is estimated that  a  pregnant woman who gains 12 kg of body weight, will  deposited daily  0.1, 0.5 and 0.9 g of protein respectively each trimester. It is recommended that the additional protein intake should be 15 g per day. assuming  a dietary protein quality of NPU 65. Thus total daily requirement would be 65 g.
The extra amount of protein  will not present a problem, if the woman consumes the recommended extra 300 kcal with a well balanced diet.

The extra carbohydrate and fat required  should be met by a normal diet.
The linoleic acid requirement during pregnancy is 4.5% of energy.
It is suggested that a desirable visible fat intake would be 30 g/day i.e., 10 g more than the desirable intake for an adult non-pregnant, non-lactating woman.
There is evidence that preterm infants need w3 fatty acids. These are not added to most formulas however there are some "super formulas" e.g. S20 Gold that add extra w3 acids
They suggest that adding w3 fatty acids can improve later IQ by 10%.
Margaret Lahey [2] reports that essential fatty acids are more likely to improve cognitive development if fed to preterm infants rather than full term babies

Vitamin A
Requirements are based on the vitamin A content of livers of the new-born and the additional intake required is very small, about 25 mg/day throughout pregnancy.
Hence, the RDA during pregnancy is the same as it is for a non-pregnant, non-lactating women at 600 mg retinol and 2400 mg of b-carotene/day.
B vitamins:
The requirements for thiamine, riboflavin and niacin are related to the energy allowance. This requires an additional recommended intakes of  :

• Thiamine                        0.2mg/day ,
• Riboflavin                       0.2mg/day,
• Nicotinic acid                 3.0mg/day
• Pyridoxal phosphate       4.0 mg/day
• Folate                             200 to 300 mg
• Vitamin B_12,                     0.5 mg/day

 Supplements of folate and B₆  may be required to meet the additional requirement of

 Iron and iodine are the two minerals of great concern since, deficiencies of these are commonly encountered. There is no recommendation on extra  iodine  intake. The RDA for iodine is 50 mg/day.

Iron requirements in the first trimester of pregnancy are unchanged i.e., 0.70 mg. The requirements of iron are depicted in Table 3.

Table 3 ---- Iron Requirements (in mg) of Women
Woman classified	Basal	Growth	Menstrual blood	Total requirement
Adult woman (body weight =50 kg)	14	--	16	30
Pregnant woman	14	46	--	60
Lactating woman	14	16	--	30

 In the second and third trimesters, the requirements increase to 3.3 mg and 5 mg, respectively. Normal iron absorption from vegetarian diets is low (2.0-5.0%) but during pregnancy, it increases to 8%. The dietary requirement is set at 37.5 mg/day.

Cautioned has been warned that iron supplementation can increase red cell size which may increase blood viscosity to a degree which could impair uteroplacental blood flow. This could affect the growth of the foetus. Supplication should proceed if the normal diet has adequate iron because the woman can adapt to absorb more

Undernutrition in foetal life or immediately after birth may have a permanent effect on

• the structure, physiology and metabolism of the body.
• altered gene expression,
• reduced cell numbers,
• imbalance between cell types,
• altered organ structure
• changes in the pattern of hormonal release and of tissue sensitivity to hormones

 Coronary heart disease (CHD)
                        is  associated with

• thinness and stunting at birth
• small head circumference
  • these results from reduced foetal growth at particular stages of gestation.
• mothers with low weight in pregnancy.

Hypertension
                    is associated with

•  LBW,
• thinness and stunting at birth.

• Associated with low muscle bulk at birth

Requirements during lactation ---- Humans are unique in regard to a  very slow rates of neonatal growth, this slow growth means there is no a massive demand for milk compared to other mammals   A woman only needs to increase her food intake by about 25% satisfy the demands  of lactation, compared to  a dog with 8 or more pups that must increase her intake by 300% or more.

• Milk volume:
  • varies widely  among individuals.
    • range from about 550 to 1000 g/day.
    • Volume of milk produced is  not  associated with maternal nutritional status
      •  there is great similarity among mothers with widely varying nutritional status.
    •  no  relationship between diet and human lactation.
    • buffers for milk production include
      • the mother's nutritional stores,
      • diet,
      • reduction in physical activity
      • metabolic adaptations
    •  milk production is depends infant demand.
      • both endocrine and autocrine control mechanisms operate to adjust milk volume in response to the infant's suckling behaviour.
      • strongly affected by feeding other foods or fluids to the infants.

• Milk energy concentration :
  • energy density of human milk depends on the relative proportions of protein, fat  lactose.
  • In well nourished populations breast milk composition is
    • fat  37-40 g/l
      • more than  half  the total kj.
    •  lactose 70-74 g/l
      • contributing 40-45% of total kj.
    • protein  9-10 g/l,
      •  5-6% of the total kj.
  • the  mother's postpartum body composition determines  fat the concentration in breast milk and thus its energy density.
    •  maternal BMI was positively associated with milk energy density and birth weight of the infant.
      •  milk volume was increases with birth weight
      • milk energy density decreases
  • best predictor of milk volume or energy intake of the infant.
  • fat concentration and energy density may not affect the total energy intake
    •  infants who are allowed to nurse on demand  compensate for a  energy density with  higher volume intake
  • Fat content of breast milk of women  enrolled for weight loss programme did not show any decrease with average weight loss of 4.8 kg during a 10-week study period.
  • Women with adequate fat reserves, can loose  up to 0.5 kg per week with no  adverse effect on lactation.
  • However calorie restriction combined with low maternal energy reserves could result in decrease in milk energy output but the critical values below which impact is significant,  have not been determined in humans.

• Fatty acids :
  • Triglycerides (TG) make up 98% of the lipid in milk
  •  there is a wide variation  in fatty acid composition of milk TG.
    • Medium-chain fatty acids are synthesized only in mammary alveolar cells using glucose or acetate as precursors
    •  saturated and unsaturated long-chain fatty acid (>16 carbons) enter the mammary alveolar cell from the plasma
      •  derived from the diet or lipid stores.
      • plasma long-chain polyunsaturated fatty acids (LC-PUFA) are produced by desaturation and elongation of the essential fatty acids
      • However human mammary epithelial cells can  synthesis of LC-PUFA,
        • it is not clear as to how much of LC-PUFA are synthesized in the breast and how much is derived from plasma.
  • Fatty acid composition of the milk is determined by  lipid and carbohydrates in the mothers diet.
    • The milk of American women 8% of PUFA in 1959
    •  and increased to 16% in 1977 when corn oil replaced animal fat as the cooking
    • Nigerian women who consume large amounts of fish, have greater w-3  LC-PUFA than do European women.
    •  Medium-chain fatty acids, are only 10 to 12 %t in the milk of Western women who derive 25-40 % of calories from fat
    • Medium-chain fatty acids are 18% in the milk of Nigerian women who consume low fat-high carbohydrate diets.
    •  medium-chain fatty acids can be as high as 30-45 per cent in response to low fat diets with relatively small or no change in the total fat content of milk,
      • implying a diet induced balance between lipid synthesis in the breast and import of plasma derived fatty acids (diet).

Protein :

• Most cross-sectional studies of populations that differ in protein intake do not indicate much difference in milk protein concentration.

• Micronutrient  :
  •  Lactating women are more likely to suffer from micronutrient deficiencies than from shortage of dietary energy or proteins
  •  milk composition is affected by the mother's intake of water soluble vitamins,
  •  consumption of fat soluble vitamins has little effect
  •  maternal mineral intake has little effect
  • where breast milk concentration is influenced by maternal intake increases in  maternal intake only increase milk content up to a maximum
• Fat Soluble Vitamins
  •  Vitamin A in milk  depends on the mother's  status of the vitamin.
    • well nourished women have 2-3 mmol/l of vitamin A in milk
    • with vitamin A deficiency  produces values of 1 mmol/l in milk
      • At the 1 mmol/l in milk the infant will accumulate no storage vitamin
        • a state of subclinical vitamin A deficiency.
        • Supplementation  provides substantial amounts of the vitamin to the infant.
      • protein is required to  transfer of vitamin A from maternal blood to breast milk  i.e.. protein bound retinol (RBP-R).
        • low Vit A status can result from
          • Low maternal zinc status,
          • protein-energy malnutrition a

•  Water soluble vitamins:

• the content of thiamine, riboflavin, vitamin B₆ and ascorbic acid in the milk are determined by maternal intakes  and supplementation can increases the levels in the milk.
• only severe maternal deficiency  of folate will lower folate  in the milk . In this case the mother's folate status at the expense of the milk.
• maternal plasma vitamin B₁₂  determines it's concentration in the milk,
• maternal vitamin B₁₂ status is important both during pregnancy and lactation to ensure adequate vitamin status during infancy.
• Minerals
  • Selenium in breast milk is related to the selenium intake of the mother.
    • Selenomethionine supplements at about 3 mmol selenium per day  increase the  selenium in both maternal plasma and breast milk.
  • Calcium is independent of current dietary intake.
    • there are large differences in  between women
      • 200 mg/dl in some areas of Asia and Africa
      • 300 mg/dl in parts of Europe and the US.
    • In India
      • New Delhi (202 mg/dl),
      • Boroda (208 mg/dl)
      • Coonoor (363 mg/dl) .
    • Calcium supplementation (1000 mg) did not increase the mineral concentration in the milk among Gambian women.
    • there are major physiological alterations in calcium and bone metabolism during lactation,  independent of maternal dietary calcium intake.
      • Bone resorption and bone formation are high,
        • first 3-6 months of lactation.
      • Decreased urinary calcium excretion
         Increased calcium absorption efficiency .
•  Iron nor copper
  • Neither maternal iron nor copper deficiency affects the secretion of these trace elements in breast milk, nor does supplementation.
  • However, inadequate intake of iron will deplete maternal stores. Iron supplementation should be recommended to the anaemic lactating woman .
• Iodine
  • Milk iodine, is independent of diet mother but an optimal iodine intake is recommended  in regions of endemic iodine deficiency.