Nutrition During Pregnancy and Lactation

Nutrition for Infants and Toddlers

Health Threats to Children

The most critical threats to the lives of children under age five globally are:  Pneumonia (18%)  Diarrheal diseases (15%)  Pre-term birth complications (12%)  Birth asphyxia (9%)  Under-nutrition is an underlying cause of ~1/3 U5M Sub-Saharan Africa > 50% deaths due to malaria, diarrhea, pneumonia

Mother’s Day Report Card

 Each year Save the Children publishes the Mother’s Day Report Card which includes data on the health of women and children worldwide  Highly recommended reading for anyone who works with children  2013 Report released this morning!

Best country for women & children Finland

 Life expectancy girl born today = 83  Under 5 mortality rate: 2.9 deaths/1000 live births  Lifetime risk of dying as a result of pregnancy or childbirth: 1 in 12,200  many countries are lower  E.g. 1/25,500 in Greece 

Save the Children

, May 2013 Report

United States Data (2010 data)

 Life expectancy girl born today = 82  Under 5 mortality rate: 7.5 deaths/1000 live births  Lifetime risk of dying as a result of pregnancy or childbirth, 1 in 2,400 women

United States Data

Childhood Obesity begins young in the US  9.5 % of children under the age of 2 are overweight, 11.5 % are obese  23.3 % of children ages 2 – 5 are overweight or obese

Country Finland Lifetime risk of female mortality due to pregnancy or child birth 12.200

Life expectancy 83 U.S.

2,400 82 Under 5 mortality rate 2.9

7.5

Worst country for women & children – DR Congo

 Lifetime risk of dying as a result of pregnancy or childbirth: 1 in 30  1 in 6 babies born will die before age 5  90% of women will have a child die befor age 5  Life expectancy girl born today = 45

Where is DR Congo?

Afghanistan 10 worst countries for women and children

Somalia

 Life expectancy girl born today = 52  Under 5 mortality rate: 180 deaths/1000 live births  1 in 16 women die during pregnancy or childbirth  36% of children under 5 are underweight for their age  70% lack access to clean water

One island, two health stories

Country Lifetime risk of maternal mortality, 1 in: Life expectancy (2009) Under 5 mortality rate, per 1000 births % undernourished ( 2009 ) Access to clean water (2009) Dominican Republic 240 76 24.7

4 86% Haiti 83 63 70 22 40% In Haiti, 73% of children 6-24 months and 60% of pregnant women are anemic.

Zambia – Quick Facts

 1 in 37 women die from pregnancy related disorders  1 in 82.9 children die before the age of 5

“Life-Saving Six” for Keeping Babies Alive, Nutrition Matters

1.

2.

3.

4.

Iron (mother and child) and folate (mom) Breastfeeding – 1 st 6 months exclusively Complementary feeding – 6 mos + Vitamin A ( 2 doses /year, child) 5.

 Zinc (child) Decreases diarrheal deaths 6.

Hygiene, water, sanitation

“Mortality” Definitions

 Neonatal mortality rate  death of infants in the 1 st 28 days of life  Infant mortality rate  death of infants in the 1 st year of life  Both are reported in deaths/1000 live births

Neonatal (<28 days) Mortality Data

Population U.S. overall Neonatal mortality rate, deaths/1000 live births 4.19

Year 2009 Maine Black infants White infants 4.2

8.2

3.43

2006 2009 2009

Infant (<1 yr) Mortality Data

Population U.S. overall Black Infant mortality rate, deaths/1000 live births 6.8 5.7

6.7

6.39

6.05

12.7

Year 2001 2004 2008 2009 2011 2009

Infant (<1 yr) Mortality Data

Population Infant mortality rate, deaths/1000 live births Year U.S. overall Black infants White 7.0

6.42

14.3

12.71

5.8

5.27

2002 2009 2002 2009 2002 2009

More Recent U.S. Data

Infant mortality rates, by state: U.S. - 2010

Percent change in infant mortality rates, by race and ethnicity: United States, 2005 –2011

Leading causes of infant death in 2011 U.S.

1.

2.

3.

4.

Congenital malformations Pre-term/low birthweight Sudden infant death syndrome (SIDS) Maternal complications 5.

Unintentional injuries Together, these 5 causes accounted for 56% of all infant deaths in the United States in 2011

Infant Mortality

 Lowest rates for mothers in their late 20’s early 30’s  Adolescent mothers have the highest infant mortality rate in US  Infant mortality is  83% higher in unmarried mothers  Higher in smokers  Higher in pre-term infants

Maternal Mortality

 All US women: ~12.7 deaths/100,000 live births  White women: 10.5 (risen)  Black women: 28.4

 Hispanic: 8.9

 2007 data

Infant Mortality

 Many of the deaths can be attributed to:  Poor maternal nutrition  Low birth weight/pre-term babies  Lack of prenatal care  Lack of health insurance  SIDS 

Nutrition before and during pregnancy is critical to the health of baby

Nutrition During Pregnancy

 Time of significant growth for mother and fetus  Goal is to start pregnancy with full nutritional stores

Nutrition During Pregnancy

 Of greatest importance pre-pregnancy are having adequate levels of:  Folate  Iron

Caloric Needs and Weight Gain

Trimester

1 st 2 nd and 3 rd

Recommended Weight Gain Caloric Needs

2-5 pounds total ~1 pound/week Few extra calories, make healthy choices + 350 - 450 kcal/day

Weight Gain Recommendations

Starting Weight Weight Gain, lbs

Underweight Healthy Weight Overweight Obese Teen Twins 28-40 5 lbs 1 st trimester 25 - ~35 15-25 Minimum 15 Upper end of above ranges 35-45

Weight Gain

 Insufficient maternal weight gain increases risk of low birth weight baby (LBW)  LBW = birth weight less than 5 ½ pounds  LBW are 40x more likely to die in the first year of life than healthy weight baby  1 in 12 babies in US are of LBW  Black 2x as likely to have a LBW baby as white/Hispanic

“Morning” Sickness (MS)

 ~75% of women experience MS during the first months of pregnancy  May be triggered by foods, smells, thought of food  May be related to enhanced sense of smell  Iron supplements may trigger nausea in some  May occur any time of day  Suggestions?......

Weight Gain

 Sharp weight gains may signal:  Water retention  Pregnancy induced hypertension ~7% pregnancies  May be associated with low vitamin D levels  Preclampsia – mild hypertension  Eclampsia – more serious  Previously called toxemia

Eclampsia

 At greatest risk:  Over 35 and under 17  Carrying twins or more!

 Family/personal history of  Diabetes  First pregnancy  African American descent

Eclampsia

 Symptoms/consequences  Edema  Hypertension  Protein in urine  Kidney failure  Liver damage  Convulsions and death of mom and/or baby

Eclampsia

 Treatment  Bed rest  Magnesium sulfate (diuretic)  Deliver baby

Nutritional Needs - Pregnancy

 Protein  Needs increase by 25 g/day  1.1 g protein/kg body weight  Page 521 has a good summary of all nutritional needs

Minerals

 Minerals  Calcium, no increase  The number of calcium binding proteins increases in the SI. This results in increases absorption.

 Critical that diet includes 3-4 servings of calcium rich foods each day.

 Iron needs nearly double  Zinc needs go by ~30%  Zinc is found in proteins

Vitamins

 B Vitamins  RDA for all goes up by ~30%  Folate needs go up by 50%  Eat more vegetables and select whole grain products.

 Vitamin C  Need a little extra

Vitamins

 NO EXTRA needed for:  Vitamin D  Vitamin A in the form of active vitamin A  DO NOT TAKE VITAMIN A SUPPLEMENTS DURING PREGNANCY  Increases the risk of serious birth defects  Extra beta-carotene (plant form of vitamin A) is fine and probably good for you

Practices to AVOID

 Smoking  Increases risk of LBW, miscarriages, infant death  Caffeine (?)  Heavy coffee drinking may lead to and increased risk of LBW  High levels of caffeine may increase the risk of miscarriage

Practices to AVOID

 Fasting or low/no carbohydrate diets  Ketones may slow fetal brain development  Aspartame (?)  Probably OK as long as mom does not have PKU  Recommend no more than 1 Liter of diet soda per day

Practices to AVOID

 Eating unpasteurized dairy products, raw cabbage, raw meats  Brie, feta, blue cheeses, goat cheeses  Increased risk of Listeria  Flu-like symptoms  May cause miscarriage and death of mom

Practices to AVOID

 Vitamin megadoses  Alcohol  Increases risk of fetal alcohol syndrome (FAS)

FAS

 Brains of 6 week old infants

No FAS FAS

FAS

 Physical Characteristics  Broad, short, flat nose  No dimple above lip  Narrow eyes  Flat face

Practices to AVOID

 Illegal Drugs  Marijuana and cocaine can increase risk of:  LBW  Nervous system disorders  Irregular heart rate  Drug withdrawal symptoms in infant  Neonatal death

Practices to AVOID

 Over the Counter Medications (most)  Can cause complications during pregnancy and increase risk of birth defects  No aspirin or ibuprofen in the last trimester  Both interfere with blood clotting

Nutrition During Lactation

 Energy needs  ~+500 kcal/day for the first 6 months  Maternal weight loss during lactation  Recommend a loss of a maximum of 1-2 pounds/month

Nutrition During Lactation

 Vitamins needs go up for:  Vitamin A, E and C  B vitamins in general

Nutrition During Lactation

 Minerals  Iron  Return to pre-pregnancy levels  Calcium  Increased absorption takes care of needs 

Adequate fluid intake is critical

Breast Feeding Benefits

 First 2-3 days breast milk contains colostrum  Contains antibodies that protect baby from infection  Reduces incidence of allergies and eczema.

 Lowers risk of obesity later in life

Breast Feeding Benefits

 Reduces the risk of urinary tract infections, inflammatory bowel disease, gastroenteritis, ear infections, and respiratory infections.  Formula-fed infants are three times more likely to suffer from ear infections than breastfed babies, and up to five times more likely to suffer from pneumonia and lower respiratory-tract infections.

Breast Feeding Benefits

 Causes less stomach upset, diarrhea, and constipation than formula.  Lessens the risk of SIDS.

 Although the connection is unclear, breastfed infants account for only half as many SIDS cases as formula-fed infants do.

Feeding Infants

 Breast milk is best source of nutrition for an infant  Assumes mom is well fed  Can be the only source of nutrients for the 1 st 4-6 months

Infants

 Breast fed babies are generally given vitamin D supplements  Especially important if limited sun exposure or if mom is vitamin D deficient  Issues occur most often with dark-skinned mom/baby

Breastfeeding

 Pros?

 Cons?

Feeding Infants

 NEVER SCOLD a new mom who decides not to breastfeed!

Feeding Infants

 A baby grows faster in the first year of life than ever again  Birth weight doubles by 4-6 months  Birth weight triples by age 1

Formula

 Formula guidelines:  Should be iron enriched 

Never

water down 

Do not add cereal to the formula

 Infants cannot digest starch  Cereal acts as a fiber and not a source of nutrition

Adding Solids to the Diet

 At ~4 6 months the baby’s iron store will be depleted  At this time (usually) the baby:  can sit up on his/her own  has doubled his/her birth weight  Any earlier introduction of solid foods can increase the risk of allergies and obesity later in life

Adding Solids to the Diet

 Start with iron enriched rice cereal first  Fewer allergies to rice than other grains  Add foods one at a time  Vegetables and fruits first

Adding Solids to the Diet

8-10 months add: egg (?) and potato, meat (last)  Eggs are controversial! I checked a number of resources. Many list adding cooked eggs to the diet at this point.  Most recommend adding eggs to the diet at 12 months  Concern is that baby will develop an allergy to the proteins in the egg white

Adding Solids to the Diet

 Avoid sweetened baby foods  NO HONEY  May carry botulism

8-9 Months of Age

 Baby can be fed “family food”  Lightly seasoned  Cooked  Finely chopped  Allow some self-feeding 

Messy

, but good for baby’s development

Messy Babies!

Feeding a 1 year Old

 OK to add whole cow’s milk to diet  Growth rate slows and caloric needs don’t go up much  So don’t stress if your soon to be toddler isn’t eating as much as you think he/she “should”

Feeding a 1 year Old



Need increased muscle and bone strength to support walking

 Protein needs go up  Calcium and phosphorus needs go up  2-3 glasses of milk are sufficient  More may lead to “milk anemia”

Feeding a 1+ year Old

 Remember – children have small stomachs, therefore it’s important that all that goes in be of high quality 

All foods should be nutrient dense



Tips for feeding a strong-willed toddler/child

 http://www.eatright.org/Public/content.aspx

?id=8057

Foods to avoid – due to high risk of choking         Popcorn Peanuts Raisins, whole grapes Uncut, stringy meats Hot dog pieces Hard, raw fruits or vegetables such as apples, green beans, carrots Chunks of meat, cheese or any other hard-to-chew foods Sticky foods, such as peanut butter, which can get stuck in the back of the mouth

Ask the Dietician: Feeding Infants and Toddlers This site has terrific information. I highly recommend it. Tips for Feeding Toddlers This site has links to nutrition during pregnancy, lactation