PERINATAL NUTRITION

Rama Bhat , MD.Department of Pediatrics,University of Illinois HospitalChicago, Illinois.

•Nutrition during pregnancy and lactation

•Nutrition during infancy.

Nutrition During Pregnancy

• Improved maternal nutrition benefits both mother and infant.

• Maternal nutrition has a major influence on birth weight.

Birth Weight as an Indicator of Risk

a) Low birth weight has high risk for coronary heart disease

b) Higher risk for hypertension

Earlier maternal nutrient restriction increases placentalsize and alters the expression of genes regulating glucocorticoid and renin angiotensin systems.

Genetic and Environmental Contributions (%)To Birth weight

Genetic 38 %Maternal genotype 20 %Fetal genotype 16 %Fetal sex 2 %

Environmental 62 %General Maternal environment 18 %Immediate maternal environment 6 %Maternal age & Parity 8 %Unknown environmental 30 %

Weight gain recommendations for pregnancy

BMI(Weight for height) Recommendedgain

Low BMI ( <19.8 ) 12.5 - 18 kg (28-40 lbs)

Normal BMI (19.8 - 26.0) 11.5 - 16 kg (25 - 35 lbs)

High BMI (26.0 - 29.0 ) 7 - 11.5 kg(15 - 23 lbs)

Obese (BMI > 29.0) 6 + kg (15 + lb.).

BMI = ( Wt. In kg./ht. In m2)

National Academy of Sciences 1990.

RDAs of Nutrients during Pregnancy

Energy(Kcal) 2200 2500Protein(g) 44-50 60Calcium(g) 0.8 1.2Iron(mg) 15 30Folate(mcg) 180 400Zinc(mg) 12 15Phosphorus(mg) 800 1200Vitamin D (mg) 5 10

Non-Pregnant Pregnant

NUTRITION DURING PREGNANCY Energy Requirement

•Cost of extra work during pregnancy has been estimated 85,000 calories.•41,000 calories for protein and fat stored in products of conception.•36,000 calories from increased O2 consumption.•8,000 calories to convert dietary to metabolizable energy.

RECOMMENDED COMPOSITION OF MULTIVITAMIN AND MINERAL SUPPLEMENTS

FOR PREGNANT WOMEN

Mineral Requirement

Calcium 250 mgCopper 2 mgFolate 300 ugIron 30 mgVitamin B6 2 mgVitamin D 5 ugZinc 15 mg

National Academy of Sciences 1990.

CALCIUM METABOLISM IN PREGNANACY

99% of calcium is in the skeleton Total body calcium: 1200 grams. 1.0 % of calcium is in the ECF.

Calcium is essential for:• nerve conduction• muscle contraction• blood clotting• membrane permeability

CALCIUM METABOLISM IN PREGNANACY

• Calcium requirements increase by 33 % during pregnancy.

• Net transfer across placenta is about 25 - 30 grams.

• Calcium transfer is active.

• RDA for calcium during pregnancy is 1200 mg.

IRON METABOLISM IN PREGNANCY

Iron is needed for:

• Expansion of red cell mass. • The fetus and placenta • Replace the blood loss at delivery

IRON METABOLISM IN PREGNANCY

•Iron requirements double during pregnancy•Estimated total pregnancy iron needs is 1000 mg•Mother transfers about 200 - 300 mg of iron to the fetus.•Iron absorption during pregnancy increases to 20 - 40 %.•Iron deficiency in the mother does not lead to iron deficiency in her infant

ADVERSE EFFECTS OF IRON DEFICIENCY

Mother:

• Fatigue• Leucocyte function• Tolerance at delivery• Preterm delivery ( OR 1.9)

Neonate: Low birth weight Neonatal death(developing countries)

Vitamins

Deficiency increases:

• NTD (Meningomyelocele and anencephaly).

• Low birth weight

• Prematurity

Folic acid:

• helps to produce additional blood cells

• helps to support rapid growth of placenta and fetus (needed for DNA)

VITAMINS

Folic acid:

• Supplementation decreases NTDs (3.6 - 1.0 %).

• In USA alone 2000 - 3000 infants are born with NTDs.

• Worldwide incidence 300 -400,000/yr.

MRC VITAMIN STUDY

• Randomized control trial

• Double blind using a placebo

• Four treatment groups

• A. Mineral + folic acid• B. Mineral + Folic acid + M.V.• C. Mineral + Placebo• D. Mineral + MV (- Folic acid)

Comparison:A + B vs C + D Folic acid effectB + D vs A + C Effect of other vitamins

MRC Vitamin Study

0

1

2

3

4

5

A+B C+D

NTD risk (% )

21/602 (3.5%)

6/593 (1.0 %)

WITH FOLIC ACID WITHOUT FOLIC ACID

Relative Risk = 0.29

(95% CI 0.12 - 0.71, p< 0.001)

NT

D r

isk

(%)

Pregnancy and Physical Activity

• Source of considerable debate• Outcome of well conducted studies

• Increased activity does not result in increased absorption.

• Active women have less difficulty during labor.• Infants of very active women were

smaller.

Advice: Exercise in moderation during 3rd trimester.

FOOD CRAVINGS AND AVERSIONS

Dietary changes during pregnancy:

• Some by advice of the physician.• Some by folk medical beliefs.• Some by change in appetite.

Food cravings:

• Sweets and dairy products.

Aversions:

• Alcohol, coffee and meats.

FOOD CRAVINGS AND AVERSIONS

Cravings and Aversions are notnecessarily deleterious.

SOCIAL AND ENVIRONTMENTAL FACTORS

• Drug abuse

• HIV infection

DRUG ABUSE DURING PREGNANCY

• Prevalence 10 - 15%.• Commonly Abused drugs:

* Cocaine* Heroin* Marijuana* Tobacco* Alcohol* PCP

ALCOHOL ABUSE

• Increased incidence of addiction (18 - 52%).

• Poor maternal nutrition.• Fetal alcohol syndrome ( 1.9 -

2.2 /1000)• CNS involvement• growth retardation• fetal dysmorphology

HIV INFECTION

• Nutritional Deficiency with AIDS

• protein caloric Malnutrition• Zinc and selenium deficiency• Calcium and Magnesium• Vitamin A, B6, B12, C, E deficiency

BABY BUILDING BASICS

• Choose food from all FIVE food groups.• Aim of 25-35 lbs weight gain.• Add 300 calories/day to your diet.• Add calcium supplement (100mg/day).• Add daily prenatal vitamins.• Avoid alcohol and smoking.• Do not eat raw or uncooked foods.• Drink 64 ounces of fluid.

Nutritional Assessment

Dietary Evaluation &RecommendationAccess to Registered DieticianEvaluation Nutritional Status

Weight for HeightEating Habits.

Modification of the Diet to Existing Medical Condition

Benefits of Maternal Nutrition Services

Preconceptional Prenatal Postpartum

Improves overallmaternal healthAllows time tochange habitsAllows reduction of risk factors prior to conception

Improves birthweight,may reduce perinatal morb.Impr. Maternalhealth & comfort, incr. initiation ofbreast feeding.

Increases breast-feeding successimproves mat.nutrition.Provides opportunity topromote healthfuleating for entirefamily.