Nutrition During Pregnancy

Preconception
Infertile may result from large BMI, male factor, ovulation defect, fallopian
tube defect, endometriosis, and/or environmental causes
Women less than 17% body fat dont menstruate, & those with less
than 22% often dont ovulate. Women with greater than 120% IBW
have fertility issues.

Ovarian hyperstimulation syndrome (OHSS), ovarian enlargement,
bloating and fluid wt gain. Discomfort can cause anorexia, nausea,
vomiting, and altered nutrition, with wt changes

Assisted Reproductive Technology (ART) Controversial-
involves in vito fertilization (IVF), cryoembryo transfer, IVF with
donors oocytes, intracytoplasmic sperm injection (ICSI), or
gestational carrier.

Conception
Chronic dieting may lead to amenorrhea (reduces fertility)

Overeating leads to increase adipose tissue, infertility, and disease risk; from
an increase of testosterone in relation to estrogen.

Polycystic ovarian syndrome have greater risk in becoming pregnant

Environmental conditions, toxins, dioxins, polybrominated biphenyls (PBBs),
phthalate esters, and other industrial products can affect fertility.

Elevated plasma homocysteine & deficiency of B12 results in infertility.

Conflicting evidences: maternal caffeine consumption linked to spontaneous
abortion?- do to the high levels of caffeine increasing fetal death. However,
overall diet, water supply, life style habits need to be considered along with
the consumption of caffeine.









Pregnancy
270days (9mo):
1. Healthy spermatozoas penetrate cervical mucus, ascend through uterotubal tract,
and fertilize a healthy ovum within 24hrs.

2. In 6-7days post, implantation of the blastocyte occurs.

3. On day 7 or 8, the trophoblast proliferates and invades the endometrium and
begins to produce HCG (human chorionic gonadotrophrin).

1
st
trimester: organogenesis; development of heart, brain, CNS,
kidneys.
Wk 1 & 2- zygote divides, implantation occurs.
Wk 3 & 4- CNS, eyes, ears, and then genitals, kidneys, palate,
and teeth develop
Post wk 4- pregnancy is apparent
Wk 9- ends the embryonic period, and fetal develop begins.

Maternal nutrition status is evaluated for an estimation of the infants
birth weight, risk of neutral tube defects (NTDs), and fetal alcohol
syndrome. As well the womens air quality and purity of water.

Two indicators of maternal nutritional status that had correlated with
infant birth weight are maternal size (height & pre-pregnancy weight)
and pregnancy weight gain. Women of large size generally have large
babies. Large babies from underweight women would likely require
an operative delivery. Recommended weight gains are based on pre-
pregnancy BMI.

Malnutrition is a major problem for reproduction, anorexia, bulimia,
which affect up to 5% females of reproductive age, causing
amenorrhea, infertility, and miscarriage.

Birth weight is a high predictor of infant mortality & morbidity.
Newborns born small for gestational age (SGA) are at great risk for
long-term health adversity such as hypertension, obesity, glucose
intolerance, and cardiovascular disease.
- 10% of pregnancies are considered high risk
- Approx. 3% of all pregnancies has some degree of birth
defects






Low birth weight (<2500g), & Very low birth weight (<1500g)
majority risk of prenatal mortality (# of infant deaths occurring
between 28wks gestation and 4wks postpartum), which encompasses
necrotizing enteroloitis (NEC), respiratory distress syndrome,
intravascular hemorrhage, and cerebral palsy. With other risk of
developmental delays, and learning disabilities, ADHD.

The size of the placenta is an indicator of placenta health, which
determines the amount of nutrition and oxygen delivered to the fetus.
Underweight women usually have lighter-weight placentas and
increased risk for delivering a LBW infant.

Less than the total weight gain resides in the fetus, placenta, and
amniotic fluid; with the remaining found in maternal reproductive
tissues, fluid, blood, and maternal stores,- component largely of
body fat.
Generally increasing subcutaneous fat in the abdomen, back,
upper thighs serves as an energy reserve for pregnancy and
lactation.

When obese, theres risk of gestational diabetes, pregnancy induced
hypertension (PIH), c-section delivery; also late pregnancy (>28wks)
and term intrauterine fetal demise (IUFD) or miscarriage. The risk is
great in delivering an infant with cardiac defect, NTDspinal bifida,
and macrosomia (> than 4000gm).

The adequate folate intake at 600mcg/day (as well as Vit B12
enzyme which metabolizes folate, iron, magnesium, and niacin)
provides less protection against obese women than normal weight.
















Complications with High-Risk pregnancies:
Anemia

Cardiovascular issues- HTN, preeclampsia, DVT

Endocrine issues- polycystic ovarian syndrome, thyroid disease, gestational
diabetes, Type I diabetes

Gastrointestinal issues- food allergies, celiac disease, gastric bypass, crohns
disease, ulcerative colitis

Hyperemesis gravidarum/nausea & vomiting of pregnancy

Infections- HIV-AIDS, malaria, chicken pox, rubella, West Nile, parvovirus,
Lymes disease, dental disease
Organ transplants- heart, kidneys, liver, lungs, stem cells

Premature rupture of membrane- early rupture of chorion (outer layer), and
amnion (inner layer), which makes up the amniotic sac

Placenta previa- abnormal presentation of placenta obstructing the cervix;
may be complete or partial; cannot deliver the fetus
naturallyonly c-section

Psychiatric- eating disorders, depression, bipolar disorder, Munchausen
syndrome, suicidal ideation

Reproductive issues- incompetent cervix, uterine anomalies, fibroids;
multiple gestations; ovarian hyperstimulation syndrome

Respiratory issues- asthma, tuberculosis

Surgeries- emergent appendicitis, gastric by-pass, cancer


Pregnancy post-gastric by-pass:
Pregnant weight loss has increase rate of becoming pregnant, especially 1yr
after the surgery with acquaint nutrition. However, complications due occur in
pregnancy from the by-pass, such as internal hernias. Post the surgery and prior
pregnancy it is best to assess proper iron, thiamin, vit B12, vit D, vit A, zinc, and
folate to reach the womens baseline.
Obese postpartum breast-feeding women may have higher rates of anemia
than normal weight women.



Adolescent pregnancy:
Approx. 1million in US/yr; teens have higher rates of delivering LBW babies
due to poor nutrition status, infections (sexually transmitted diseases), substance
abuse usage (alcohol, drugs, smoking), lack of education, lack of social support,
limited access to prenatal care, maternal age <15yrs old, unmarried status, poverty,
low pregnancy body weight for height, and preexisting anemia.

Many teens may have deficiencies in folic acid, vitamins (A, C, D, Bs), calcium,
macro & micronutrients.

Clinical findings of during pregnancy may be poor weight gainpossible
eating disorder, low birth weight of the fetus, and premature births.

Medical management during pregnancy shall be regular prenatal care,
follow-up of infant and mother frequently, vitamin/mineral
supplementations, and ensure a pregnancy weight gain of 28-40#.

Nutritional management during pregnancy shall be meeting energy and
protein needs, importance of nutrition education for mother and fetus,
teaching of consuming a healthy diet using the food pyramid, and
encouraging the elimination of alcohol and other substance use.

Multiple births:
Incidences rising due to fertility drugs, embryo transfers, and increase
amount of older women becoming pregnant.

Nutritional supplementation during pregnancy:
Pregnant women need slightly additional energy, protein, vitamins, and
minerals than when not pregnant. Ones who are at supplement risk qualify for
USDA WIC program.
WIC program serves pregnant women and children up to 5yrs of age, non-
breast feeding postpartum women until 6months postpartum infants and
children up to the age of 5.
To qualify, one must live in area of a service, be low income, and have
nutritional risk factors, such as anemia, poor gestational weight gains,
inadequate diet, FTT of the infant/child.
WIC provides vouchers for foods high in vitamin A, vitamin C, iron, protein,
and calcium. WIC strongly promotes breast-feeding. Teaches of what types of
foods can constitute for balance, which is difficult for the ones who have
grown up on the fast food era.






Physiologic Changes with pregnancy:
Blood volume & composition- blood volume expands approximately 50% by
end of term, which decreases hemogloblin, serum albumin, and other
serum proteins, and water-soluble vitamins. Loss of albumin can
result in fluid accumulationedema to ankles. With decreased
albumin, concentrations of fat-soluble vitamins, lipids-triglycerides,
cholesterol, and free fatty acids increases

Cardiovascular & pulmonary functions- Increase output and cardiac size by
12%. Diastolic blood pressure decreases during first 2 trimesters due
to vasodilatation, but returns to prepregnancy values in third
trimester. Blood return to heart decreases, decreased cardiac output,
a drop in blood pressure, and lower extremity edemaMay associate
with larger babies and a lower rate of extremity edema.

Gastrointestinal functions- nausea and vomiting within first trimester, followed by
return to appetite with cravings . The increased progesterone relaxes the
uterine muscle to allow fetal growth while decreasing GI motility with
increased reabsorption of waterleading to constipation. The relax lower
esophageal sphincter and pressure on stomach from growing uterus cause
regurgitation and gastric reflex.

Gallbladder disease is the most common medical problem during
pregnancy, due to emptying less efficient from affect of progesterone
on muscle contractions; however theres increase in lysogencity of
bile.
During 2
nd
and 3
rd
trimester, the volume of gallbladder double
from 1
st
trimester with great loss to empty efficiently. Person
may experience constipation and dehydration as gallstones
develop. It is recommended to be placed on a low-calorie diet
or avoidance of certain foods

Celiac disease, results in higher risk of spontaneous abortion, LBW
infants, and reduced duration of lactation. Celiac disease induces
malabsorption and deficiencies of folic acid and vitamin K.
Recommended to have gluten-free products to prevent any
adverse reactions.

Renal functions- GFR increases by 50%, but urine excretion is not increased.
Increased blood volume causes the increase GFR when low creatinine and
blood urea nitrogen (BUN). Renal tubular reabsorption is less efficient than
non-pregnant
Small amounts of glycosuria increase the risk for urinary tract
infections.

Placenta- main site for hormone exchange to regulate fetal growth and development
of maternal tissues for nutrients, oxygen, and waste products.

Nourishes the fetus regardless how well nourishes the mother.

Placental insults can result from poor placent, preeclampsia, or hypertension.

Placental size is 15-20% below normal for premature/under-developed
fetus.

7.5-8.5#: Fetus
7.5#: stores of fat in protein
4.0#: Blood
2.7#: Tissue fluids
2.0#: Uterus
1.8#: Amniotic fluid
1.5#: Placenta & umbilical cord
1.0#: Breasts

25-35#: Normal weight gain (18.5-24.5 BMIs)
15-25#: Underweight (25-29.9 BMIs)
No specific wt: Obese (class I: 30-34.9 BMIs,
Class II: 35-39.9, Class III: > 40 BMI)
























Nutritional requirements with pregnancy:

Energy- metabolism increases by 15%, first trimester has no changes to
requirements, but in second trimester theres an increase of an additional
340-360kcal/day, then another 112kcal/day increase for the third trimester.
It is important to keep the pregnant womens weight gain within
normal limits

Energy expended in physical activity determines energy expenditure,
which governs weight. Excessive exercise with inadequate energy
intake may result in maternal weight gain and poor fetal growth.
When happen earlier on in pregnancy can rapidly drop oxygen to fetal
brain due to the timing when neurogenesis and neutral migration
resulting in possible brain desperations or death.

Any restrictions to energy can increase ketone production, there is
unclear effect, but fetus has limited ability to metabolize ketones.
Keytones results from fat metabolism. Risky for IDDM.

Protein- No changes to regular recommendations in first trimester, than increases
to 71g/day for the second and third trimester. In multiple births each fetus
theres an additional 25g/day recommended.

CHO- approximately 135-175g/day, just enough to provide enough calories to
prevent ketosis and maintain appropriate blood glucose. (i.e.) 175g=700kcal
& 35% of avg 2000calorie diet

Fiber- 28g/day; consist of whole-grain breads & cereals, leafy greens and yellow
vegetables, fresh and dried fruits.

Lipids- no set limit, but depends on energy requirements for proper weight gains

Folic acid- 600mcg, TUL of 800-1000mcg/day from fortified foods/supplements.
Not enough consumed risk a reduction rate of DNA synthesis and mitotic
activity in cells
Women of childbearing years are recommended to increase intake of
folic acid to prevent possible risks since most pregnancies are
unplanned & the neural tube closes by 28days gestation. Such
products are grains.

Women who smoke, consume much alcohol, use recreational drugs
are @ risk for marginal folic status, especially using oral
contraceptives, antiseizure meds (phenytoin), and malabsorption
syndromes. Women on antiseizure meds when starting folic acid
should be carefully monitored because folic acid can reduce seizure
threshold.
Choline- 450mg/day (at least 314mg/day); protects against memory loss after
grand mal seizures and memory impairments in development for from an
alcoholic mother.
Food sources are beef liver, pork, chicken, turkey, fish, egg
yolks, soy lecithin, and wheat germ.

Vit B6- 1.9mg/day; assist in further synthesis of nonessential amino acids in growth
and vitamin-b dependent niacin synthesis from tryptophan. Commonly used to
manage severe nausea and vomiting in pregnancy.

Vit C- 80-85mg/day; possible low levels relate to cause of preeclampsia- rupture of
membranes??

Vit A- 770mcg of retinol equivalents; assist in gene expression.
In human cord blood theres correlation with birth weight, head
circumference, length, and gestation duration. Lower than
recommended levels risk chances of birth defects.

Vit D- 5mcg/day; ensure calium balance, enhance immune function and brain
development.
May have role in cytokine (Th1 & Th2) regulation, implicated in MS
and recurrent pregnancy loss. Any deficiency in vitamin D may result
in preeclampsia, or pregnancy hypertension.

Vit E- 15mg/day

VIt K- 90mcg/day for adult women 19-50yo; roles in bone health for childbearing
yrs

Calcium- 1300mg/day for women 18 or younger & 1000mg/day for 18+; hormonal
factors influences maternal bone turnover, estrogen (derived from placenta),
inhibits bone reabsorption, provoking compensatory release of parathyroid
hormone, which maintains maternal calcium while it crosses the gut. Last
trimester there is about 30g calcium in part for the fetus skeleton.
Over consumption of recommendations can result in excess antacid
ingestion for heartburn of pregnancy or GERD, and/or dangerous
levels of calcium from milk-alkali syndrome.

Phosphorus- 1250mg/day for women younger than 19yrs of age, & 700mg/day for
19+yo; lower levels can be found in women with hyperemesis gravidarum






Iron- 27mg/day throughout pregnancy; few rarely have deficiencies but if does then
ferrous salt supplementation is recommended to prevent anemia.

Supplements should be taken between meals and not with milk, tea,
or coffee due to limiting absorption. However, vit C enhances
absorption.

Maternal anemia, less an 32% Hemacrit and hemoglobin less than
11g/dl. A anemic women poorly tolerates hemorrhage with delivery,
which increases cardiac stress. Also increase risk of developing
puerperal infection.

Excessive iron can implicate preeclampsia and gestational diabetes,
and elevated blood levels leading to pregnancy enhance hypertension,
which can influence uteroplacental.

Zinc- 11-13mg/day; stores in maternal skeleton; in deficiencies brain there can be
abnormal brain development.
Maternal zinc status may be inversely related to the degree of
prenatal iron levels because iron ingestion inhibits zinc absorption.

Copper- 1000mcg/day; no concluded risk with any deficiencies, but if consume in
excessive amount can inhibit copper absorption

Sodium- 2-3g/day; ionized salt of choice. Tries to maintain fluid and electrolyte
balance. A
Increase amount of salt in maternal blood increases glomerular
filtration. Strict restriction to sodium during pregnancy isnt
recommended because it can stress the rennin-angiotension-
aldosterone system, resulting in intoxication and renal, adrenal tissue
necrosis.

Magnesium- 350-400mg; reports have concluded may decrease incidences of
eclampsia and Interureine growth restrictions.

Fluoride- 3mg/day; structure of teeth, primary dentition begins 10-12wks
gestation, with first 4 molars then 8 incisors followed by for a total of 32.

Iodine- 70mcg/day; assist in roles of metabolism of macronutrients.

Supplementations before and after the third trimester can protect the
fetal brain. Maternal deficiency may result in neonatal cretinism,
which compromises fetal develop leading to developmental delays.

Many environmental influence (cigarette smoke, soil, etc) limits
exposure to iodine, producing a deficiency

Guidelines for eating during pregnancy:

Fluids- 8-10 glasses/day majority water
Suboptimal hydration in midtrimester and beyond to premature contractions
and reduced amniotic fluid volume. Frequent urination comes with
pregnancy, however, the benefits of optimal hydration includes reduced risks
of UTIs, kidney stones, and constipation.

Calcium intake- whole milk, low-fat milk, skim milk, nonfat powdered milk,
buttermilk, acidophilus milk, lactaid, evaporated milk, enriched soymilk,
enriched rice milk, enriched nut milks, and yogurt.

Approximately 1/3c of dried skim milk= 1c liquid milk

Milk can be richer in calcium, protein, and calories by adding 2TBLS of
nonfat dried milk to liquid milk

Milk fortified with vit D; animal derives D3, while D2 is not- preferred
by vegans. D2 has less than 1/3 potency than D3; with some non-dairy
milks having no vit D. A supplement of vit D is necessary when milks
are used limited and sun light exposure is limited.

Many women, mostly non-white and blacks, are unable to digest
lactose milk unless in small amounts or cooked; so recommended
supplement of calcium lactate or calcium carbonate are suggested.

Alcohol-
Fetal alcohol syndrome, specific patterns of abnormalities in the child,
such as prenatal & postnatal growth factors, developmental delay,
microcephaly, eye changes (slanting eyes/close set), facial
abnormalities, and skeletal joint abnormalities.

Use of alcohol during pregnancy increases rate of spontaneous
abortion, abruption placenta, and LBW delivery. Alcohol impacts
metabolism & nutrition exchanges. The role of alcohol exposure has a
high insulin resistance, which can lead to occurrence of type II DM.

Caffeine- consumption may increase risk of first trimester spontaneous abortions;
still further research is needed to determine the amount and risks.





Artificial sweeteners- four types: saccharin, acesulfame-K, sucrolose, and
aspartame.
Limit intake, dont have excessive. Discourage artificacly beverage
consumption.

Saccharin is a carcinogen at high levels, sucrolose is a CHO, but
600times sweeter.

Aspartame is unsafe for women with phyenylketonuria (PKU), due to
aspartame metabolized to phenylanine and aspartic acid. There is a
lack of enzyme to brake down the sugar; which can result in brain
damage at high blood phenylalanine concentration.

Contaminants- lead, insecticides, pesticides, lawn chemicals, new house out-
gassing, old Teflon pans.

Dolomite- calcium supplement may contain leadCaution

Methyl mercury: shark, mackerel, tilefish, tuna, swordfish should be
limited no more than 2xs/wk in 4oz portions

Seafood makes up 80% market; tuna, shrimp, Pollock, salmon, cod,
catfish, clams, flatfish, crabs, scallops, can al have methyl mercury
levels of <.2 ppm.
Theres no restricts for the ones who consume more than 2.2#
of this type of seafood/wk.

Farm raised fish needs to be watched for the pollution levels.

Polychlorinated Biphenyls (PCBs)- from fatty fish, salmon, trout, carp; the oils can
be absorbed through skin and lungs of contaminated fatty fish. Then, can
pass the placenta and breast milk

Listeria Monocytogenes- pregnant women are at greater risk of
becoming infected; causes spontaneous absorption and
meningitis of the fetus and newborn.

Arises from soil-borne organism, from consuming
contaminated food of animals and raw vegetables, such items
are milk, smoked seafood, hot dogs, soft cheese, cold cuts, and
uncooked meats

Wash foods carefully and thoroughly before consuming and
cook food thoroughly

Beliefs, avoidance, aversions, and cravings:
Common cravings are for sweets, dairy, or foods quick on hand

Common aversions are alcohol, coffee, caffeinated drinks, and meats

Pica- consumptions of non-food items, such as clay, grass, laundry starch, winter
outdoors ice, stones, charcoal, milk of magnesia, baking soda, coffee grounds.

Malnutrition usually occurs, most typically calcium and iron; lead poisoning
may result due to most non-food items having metals compounds. Items can
cause intestinal obstruction. Reseasons of pica are unclear, however, thought
may be to reduced nausea and vomiting

Complications of pregnancy with dietary implications:

Nausea & vomiting- affects 50-90% of pregnant women during 1
st
trimester, then
resolves around the 17
th
wk of gestation

Small, frequent, dry meals of easily digested CHO-foods may be
tolerate; whereas protein foods may reduce nausea for others.
Dry crackers and ginger ale are often prescribed for nausea,
but not a high-quality diet.

Liquid meals reduce arrhythmias more than solids; & over hydrating a
starving women reduces ketones but does not indicate adequate
nutrition.

Vitamin B6 seen to relieve symptoms in mild cases

Smelling lemons may help women block noxious background odors,
eating crackers/potato chips, vit lollypops, acupuncture, hypnosis can
help but pregnant women up to delivery

Important to keep hydrated and maintain electrolyte balance, to avoid
any cardiac irregularities and respiratory failure

In some incidences of hyperemesis or ptylinism gravidarum (excess
salvia) may need use of tube feed- nasal gastric or PEG to prevent any
symptoms






Edema/leg cramps- usually in third trimester

Normal edema caused by pressure of enlarging uterus on the veins,
obstructing the return of blood flow to the heart.

Recommended to lay on side to decrease fluid amount through and
increase in urine output

Calcium supplementation for leg cramps, and or use of magnesium
supplement, since pregnancy and lactation can lead to secondary
magnesium deficiency
Signs of deficiency are muscle tremor, ataxia, tetany,
constipation, and cramp

Heart burn- GERD mostly occurs at night in the latter part of pregnancy; due from
the enlarged uterus on the intestines and stomach, which combines with the
relaxation of the esophagus sphincter, causing regurgitation.

Constipation/hemorrhoids- results commonly beginning in 1
st
trimester from lack
of adequate water & fiber

Many pregnant women may be given zofan for nausea and vomiting to
become extremely constipated. Straining during stools increases risk
of hemorrhoids

Increase fluids, fiber-rich foods; and or a stool softer medication are
recommended for prevention


















DM- Tests are done either preconception or early on in pregnancy to control the
hormonal effects of DM to the mother and fetus.
Large risk of PHD, macrosomia, chorioamnionitis, prematurity,
intrauterine fetal demis (IUFD), and fetal morbidity with pregnant
mothers with DM.

With diagnose of GDM or having high glucose levels throughout the
terms can produce a risk.

Pregnancies without vascular disease can result in fetal macrosomia
caused by hyperglycemia from maternal blood. Fetus responds to
maternal hyperglycemia by increasing its own insulin production,
leading to excessive growth and adiposity.

Infants born to women with long-standing type I DM with vascular
disease may not be larger than those born without women with DM.
Following delivery, the infants pancreas continues to secrete
elevated levels amounts of insulin.

Since maternal blood glucose supply is no longer available,
many infants of mothers with DM rapidly develop
hypoglycemia requiring a glucose infusion.

Successful pregnancy require adequate dietary intake to meet growth
needs of the fetus, prevent ketosis, and prevent depletion of maternal
nutritional stores.

Insulin requirements decline in the 1
st
half of pregnancy because of
fetus use of glucose, the mother needs only 2/3 of the usual amount.
In the 2
nd
half of pregnancy hormone changes induce an increase in
insulin of 70-100%; occurs rapidly from the 5
th
month until termed.

Control the mothers diet with adequate CHO during this duration;
making any frequent changes in diet and insulin dosages. The number
of snacks may need to be increased for insulin-dependant women who
are lactating, it may be necessary to consume 3 small meals and 4
snacks to avoid drop of blood glucose levels that can occur with large
milk output.

Gestational DM; diagnosed within 24-28wks gestation, may be at
greater risk in developing preeclampsia, prenatal mortality, and
prematurity, macrosomia, and greater birth weights; especially if
mothers blood glucose levels are not in controlled.
A 50g oral glucose test challenge indicating a value of 135-
140mg/dl indicates GDM, obese women with value over
180mg/dl are at high suspicions for GDM.
Treatments: largely with dietary modifications, calorie restrictions
and moderate exercise to maintain appropriate weight gain. Limiting
CHO @ breakfast 10-30g with addition of 2-3oz protein mid morning
to decrease hunger and increase compliance.
Blood glucose levels are often monitored 4-6times a day with a
goal of less than 90g/dl for fasting and less than 120mg/dl
after meals.

Pregnancy-induced hypertension- includes gestational hypertension and
preeclampsia/eclampsia.

Gestational HTN, a maternal blood pressure equal to or greater than
140/90 with no proteinuria that develops after midpregnancy.

Preeclampsia, a systolic blood pressure being 90 or more, and urinary
protein of 300mg or more in a 24hr period.
Severe preeclampsia is systolic blood pressure 160 or more or
diastolic blood pressure of 110 or more and a 5g of protein in a
24hr urine test.

Preeclampsia is associated with decrease uterine blood flow,
owing to vasospasm, leading to reduced placental size,
compromised fetal nourishment, and IUGR fetus.

Eclampsia, a PIH resulting in grand mal seizures, symptoms are
dizziness, headaches, visual disturbances, facial edema, anorexia,
nausea, and vomiting. Fetal death may result in women who develop
eclampsia; with small occurrences of eclampsia present in postpartum
period; either way eclampsia can be fatal t the mother if not treated
promptly.

Magnesium supplementation is recommended to prevent and treat
preeclampsia and eclampsia.

Women who are over 40yrs, obese, black and having a family history
of PIH are at greater risk; also ones with chronic HTN, chronic renal
disease, DM, twin gestation, or hormonal instability

Lack of vitamin D has had links to PIH; vitamin C and E supplements
along with vit D are seen in positive measures for treatment &
prevention.

Vaginal infections results in a major role in premature contractions
and possible early deliveries.
Bacterial vaginosis, affecting many pregnant women can be
treated with probiotics.
Lactation

Breast-feeding for the first 4-6months are preferred; however can be
contraindicated for infants with galactosemia and mothers who have
untreated TB, or HIV.

Benefits:
Infants: decrease incidence &/or severity of infectious diseases of bacterial
meningitis, bacterium, diarrhea, respiratory tract infections, necrotizing
enterocolitis, otitis medias, UTIs, late-onset sepsis in premature infants
decrease rates of SIDS, type I or II DM, lymphoma, leukemia, Hodgkins
disease, overweight/obesity, hypercholesterolemia, food allergies, asthma,
neurodevelopment- enhances performance on cognitive development tests,
provides analgesia during painful procedures such as heel sticks, promotes
mother-child bonding

Mother: decreases postpartum bleeding, more rapid uterine involution,
decrease menstrual blood loss, increase child spacing, earlier return to
prepregnancy weight, decrease risk of breast and ovarian cancer, possibly
decrease risk to postmenopausal hip fractures and osteoporosis.

Successful Breast-feeding:
1. Policies and trained staff to assist in educating about benefits and
techniques to breast feeding
2. Help mother initiate breast-feeding within 30mins of birth
3. Educate how to maintain lactation/breast-feeding procedures even when
separated from their infant
4. Give infants no other food or drink besides breast milk unless medically
necessary
5. Allow mothers and infants to be with one another 24hrs/day
6. Encourage breast feeding on demand
7. Give no artificial pacifiers to breast feeding infants
8. Establish of breast-feeding support groups










Physiology of lactation:
Mammary gland growth during menarche and pregnancy prepares for
lactation; while hormonal changes increase breast, areola, and nipple
size.

Late in pregnancy, alveolar system is developed to form small
amounts of colostrums, thin, yellow, and milky rich in antibodies
released for several weeks before term and for few days post delivery.
Colostrum is the first milk available, and is higher in protein
and lower in fat and CHO, provides approx 20kcal/oz.

After delivery, there are rapid drops of estrogen and progesterone,
along with increase secretion of prolaction to initiate milk supply.
Stimulus of milk produce occurs by infants suckling- subcutaneous
nerves of areola send message via spinal cord to hypothalamus, which
transmits message to pituitary gland (anterior & posterior portions).
Prolactin anterior pituitary stimulates alveolar milk
production;
Oxytocin- posterior pituitary stimulates myoepithelial cells of
mammary glands to contract, causing movement of milk
through the ducts and lactiferous sinuses; let-down
processhighly sensitive.

Oxytocin secretion can be inhibited by pain, emotional and
physical stress, fatigue, and anxiety.

Women who had GDM, have DM, and/or been stressed hormonally
during delivery are at risk for delayed milk production, occurring
when signs of lactogenesis are absent 72hrs after birth.















Breast Milk: increase of most nutrients are encouraged, milk production
is most affected by suckling and maternal hydration. However, milk
composition varies depending on the mothers diet.

Energy, requirements of 100ml milk require an 85kcal expenditure.
During the first 6months of lactation, average milk production
is 750ml/day.

The DRI for energy during lactation is 330kcal greater during
the first 6months of lactation and 400kcal greater than the
following 6months; however obese women may not require
the full 330-400 extra kcal/day.

Maternal fat stores, accumulated during pregnancy provide about
100-150kcal to support the early months of lactation.
When reserve fat store are depleted, energy support for
lactation must be increase if the mother intends to provide all
or most of her infants nutrition through breast milk alone.

During the second 6months of lactation, production of breast milk
declines to an average of 600ml/day or about 20oz/day. This is due to
how many infants by this time are starting to consume solid foods, so
frequency of breast-feeding is declined with the decline needs of
energy requirements for the nursing mother.

Milk production decrease in ones who undertake rigorous calories
restated diets under 1500kcal

Healthy breast-feeding usually can lose as much as 1#/wk and still
supply adequate milk to maintain infants growth. Women who are
already lean may be proposed to risk of reduced milk production if
they restrict their energy intake, recommended energy intake is at
least 1800kcal/day.











Nutritional requirements:

Protein: additional 25g/day, or a total of 71g/day to ones diet.
However, women who had surgical deliveries or entered pregnancy in poor
nutritional shape may need further amounts of protein. Just the same, obese
or overweight women may need a bit more protein requirements.

CHO: 120-160g/day, needed to provide adequate amounts of milk volume to
prevent Ketonemia and maintain blood glucose during lactation.

Lipids: no DRI indicated but recommends specific long-chained fatty acids of
polyunsaturated fatty acids in the maternal diet for fetal and infant brain
development.
Omega-6, AI of 13g/day, and omega-3 AI of 1.3g/day. Human milk
contains 10-20mg/dl of cholesterol, which results in approx.
100mg/day infant consumption/day. Cholesterol of the milk
decreases over time as lactation progresses.

Vitamins & Minerals:
Vitamin D- 5mcg/day AI, prevent occurs of rickets, or any bone/skin
deformities.

Calcium of breast milk is not related to maternal intake, bone material
density is influenced by calcium intake up to 1600mg/day. Maternal
bone loss during lactation is approx 3-7%, which is rapidly regained
after weaning.
AI of calcium is 1300mg/day for ones less than 19yrs and
2500mg/day for greater than 19yrs.

Iodine is reflected by maternal diet, low levels may be seen in women who
are practicing a vegetarian diet. Risk to the infant from low iodine may
result in transient neonatal hypothyroidism

Zinc has high needs during lactation than pregnancy, 12-14mg/day.











Breast-feeding Technique:
Breast become fuller and firmer as milk volume increase within 48-
96hrs following birth.

Breast-feeding is a learned skill with much practice, patience, and
perseverance needed.

Allow for a comfortable position, supporting the infants
head/neck/and shoulders.
With the infant close to the mother, align the nipple opposite to
the nose, as the mouth opens wide bring the bodies body close
to the breast while aiming the nipple to the back of the infants
mouth.

Chin indenting the breast and nose touching breast. Nurse on
the first breast until satisfied then offered the 2
nd
breast; dont
limit time of feeding.

Lactating women may experience a tingling sensation in the breast,
which is the signaling of let-down reflex; sensation can be
accompanied by uterine cramps, thirst, and drowsiness.
Rest or a hot shower before nursing can help with let-down
reflex

Switch breast of feeding to maintain balance or can pump milk from
breast to be used later by the infant if away from the mother.
It may be best to avoid supplemental bottle feedings until milk
supply is establish- usually 3-4wks-post birth.

To remove the infant from the breast, a finger is placed in the corner
of the mouth until the suction is broken. This allows for reduction of
nipple trauma. The infant individualizes burping.

Breast-feeding infants may feed more frequently, 8-12 feeds/day.
signs of feeding readiness are lip smacking, rooting, suckling
movements. During growth spurs, babies feed more often for a
few days to increase the mothers supply (87% of breast milk
is water)

Infants introduced to artificial nipple in the first few wks may
experience nipple preference, which can produce a difficult time to
breast feedinglatching on. Also, the sucking on a bottle and breast
are different.

Within 3-5days of birth the infant should be followed up with the
doctor.

Duration: depends on the infant, exclusive breast-feeding is recommended
for the first 6months, but can continue for the first year. Many are breast
breast-fed until weaned to a cup at approx age of 9-10months.
The weaning process is done gradually over a few wks.; done
gradual for easiness on the mother, avoiding engorgement of their
breast as well as a smooth transition for the infant.

Exercising: encouraged to return to normal exercise a few wks after
delivery, and lactation are established. Exercise improves plasma lipids and
insulin responds without negating maternal or infants immune status.

Transfer of drugs into human milk: most medications appear in human
milk. Ensure medication safeness prior taken with medical doctor.
Many cytotoxic drugs are known to have detrimental affects, such as
antidepressants, antianxiety, antipsychotic, and narcoleptic drugs.

FTT in Breast-fed infants: not an issue for infants who continue to gain
weight and length steadily, has at least 6-8 wet diapers/day, and has frequent
stools, the milk supply is probably adequate enough.

If the infant doesnt have the followed, poor intake is result, which declines
growth. If does occur, encourage the mother to switch to a formula for partial
nutritional support and assess the mothers nutritional intake and health.

Women who consume diets low in vitamin B12, D, or iodine will produce low
milk levels, which increases FTT signs.

Infant allergic to cows milk protein (casein), once removed and
supplemented with something different nutritional qualities improve.

Maternal causes towards FTT- poor let-down (stress, anxiety, certain
meds, HTN, smoking), and/or poor production (hyperthyroidism,
excessive antihistamine use, insufficient development of alveolar
tissue, excessive caffeine use, illness, poor diet, retained placental
fragment, and/or fatigue)

Infants causes towards FTT- high energy requirements (CNS defects,
congenial heart disease, small gestational age), low net intake
(vomiting/diarrhea, malabsorption, infection), or poor suckling
(contented, sleepy nature, infrequent feedings, craniofacial
abnormalities)

Overweight problems: women obese or overweight lactating should reduce
energy intake by 500kcal/day, by reduced consumption of foods high in fat
and simple sugars, they are recommended to increase intake in foods high in
calcium and vit D, especially from fruits and vegetables.

Breast augmentation: small breast tissue that requires implantation in
order to successfully breast feed.

Reduction mammoplasty: reduction of breast tissue for maternal healthy to
successful breast feed; takes pressure off back, neck , shoulders as breast fill
up with milk supply.

Neonatal ICU: delays initial breast-feeding times for mother and child due to
the infant born LBW or VLBW.


Nutrition During Infancy

Growth changes:
First 2yrs has rapid physical and social growth development. After birth the
growth is influence by genetics and nourishments. Most infants are determined
to be larger reach their growth channels- a curve of weight and length or
height gain throughout the period of growth, between 3-6months. However,
the infants that are born below the 10
th
percentile for length may not reach
their growth channels until 1yr of age, know as catch-up growth.
Larger infants at birth who are genetically determined to be smaller
grow at their fetal rate for several months and often do not reach their
growth channels until 13months; know as the lag-down growth.

Infants lose about 6% of their body weight during the first few days of birth,
but then regain after 7-10days. Then double their weight by 4-6months, and
triple the weight by the 1
st
yr.

Infants length increase by 50% during the 1
st
yr and double by the 4
th
yr.

Total body fat increases rapidly during the first 9months, after which the rate
of fat gain tapers off throughout childhood. Total body water decreases
throughout infancy from 70% at birth to 60% at 1yr.








The stomach capacity of an infant increases from a range of 10-20ml at birth,
to 200ml by 1yr; which enables infants to consume more food at a given time
and at less frequent intervals as they grow older.
During the first few days of birth, gastric acidity decreases and for the
first few months remains lower than of older infants and adults The
rate of emptying is slow, depending on the size and composition of the
meal.

Gastric secretion, pepsin remains low during the first 3 months of
birth, does not limit protein digestion. Human milk and commercial
infant formula of fat is well absorbed, than buttermilk.

The infant has functional but physiologically immature kidneys that increase
in size and concentration capacity in the early weeks of life.
They double in weight by 6months then triple by 1yr

The renal concentration capacity at birth is limited to as little as
700mOsm/L, as compared to adults of 1200-1400mOsm/L.

Hardly any issues to the infants kidneys, besides when the infant has
diarrhea or are fed formula that is too concentrated.




















Nutritional requirements:

Energy- full-term infants who are breast-fed to satiety and infants who are fed
standard 20kcal/oz formula adjust t their needs. Monitor weight based on
growth.

Protein- needed for tissue replacement, lean body mass, and growth. Higher
amounts needed during growth, protein intakes based on human milk.
Infants require a larger amount of essential amino acids than adults;
with tyrosine, cystine, and taurine are essential for premature infants.

The amount of protein in human milk is adequate for the first
6months, then infants shall be supplemented with additional sources,
such as yogurt, strained meats, cereals mixed with formula or human
milk.

Lipids- minimum of 30g/day for infants younger than 1yr.
Human milk constants a generous amount of essential fatty acids linoleic and
linolenic acid as well as ARA & DHA. Where as in formula, there are
supplements of lineolic and linolenic from ARA and DHA.

Linoleic acid, essential for growth and dermal integrity, provides 3%
of total kcal, or 4.4g/day for less than 6mo & 4.6g/day for infants 7mo
to 1yr. 5% of kcal in human milk and 10% in formula

CHO- 30-60% of energy, with human milk supplying 40% and formula supplying
40-50%. Some infants may not tolerate lactose, may need alternative such as
a soy based.
Botulism caused by ingestion of spores, which generate and produce
toxin in the bowels. Honey and corn syrup, and at time home-
prepared foods may be causes. Spores are extremely restraint to heat.
No honey and corm syrup to children younger an 1yr to prevent
development of spores in bowels.

Water- .7L/day for infants up to 6mo, .8L/day for 7-1yr infants; amount determined
by the amount lost in lungs, skin, feces, and urine.
Water recommendations are given frequently throughout the day
because the renal concentrations of infants from childhood are
developing.

Prevent dehydration for the infant, which are shown to be fatigue,
flush skin, tenting skin, not the same amt of wet diapers as before,
constipation



Minerals-
Calcium: 4000-800mg/day for infants who consume cows milk or consume
approximate 25-30% formula.
Breast-fed infants retain 2/3 of the calcium intake. For 0-6mo,
210mg/day & 7-12mo is 270mg/day.

Iron: required for storage, growth, and doubling birth weight, especially after
4mo for full-term infants.

At 4-6mo, infants fed only human milk are at risk for developing a
negative iron balance, which may deplete their reserves by 6-9mo.

By 6mo, the infant should be given iron-fortified supplements in the
form of cereals or infant formula.

Prevention of becoming anemic and/or iron deficient.

Low hemoglobin concentration at 8mo can correlate with impaired
motor develop at 18mo. Also, chronic iron deficiency can lead too
developmental deficits and behavioral issues.

Zinc: immediate dependant; better absorbed in human milk than formula,
however both has .3-.5mg/100kcal for the first yr, then
supplemented with other foods such as meats, cereals.

Fluoride: .7mg/dayprevents dental caries; no supplements recommended for
younger than 6yo.
Following after first tooth eruption it is recommended to use
fluoridated water several times/day to breast-fed infants,
those consuming cows milk, and/or formula made with water
containing less than .3mg fluoride/L.














Vitamins-
D- prevention of rickets and deficiencies a 200IU/day for all breast-fed,
500ml/day for fortified formula fed; human milk only contains 20IU/L
(.5mcg cholecalciferol) of vitamin D. For infants with fair skin, regular
exposure to sunlight for 30mins/wk, with the infant wearing a diaper
or 2hrs/wk if fully clothed without a hat is significant for vit D needs.

There are high risk of rickets among young, breast-fed infants and
children with dark skin.

B12- Milk from lactating mothers who are strict vegans may become
deficient especially if mother has been flowing diet for a long period of time.
Been diagnosed in infants breast-fed by mothers with pernicious
anemia.

K- 2mcg/day during the first 6mo, and 2.5mcg/day after up to the 1yr.
Deficiency may result in bleeding or hemorrhagic disease of the
newborn, commonly in breast-fed infants due to human milk
containing only 2.5mcg/L & cows milk based formula having
approximate 20 times the amount.

All formulas have 4mcg per 100kcal of formula.

Vit k injection as an infant is seen to possibility increase risk of
leukemia and cancers.

Supplementations: should be given after evaluation of infants intake. Commercial
prepared formulas are fortified with all necessary vitamins, so rarely supplements
as needed.
Breast-fed infants need additional vit D by 2months of age and iron by 4-
6months of age. Older infants fed homogenized milk need a food
source/supplement of vit C.












Breast Milk vs. Formulas:
Human milk- best choice; prevents diarrhea and otitis medius.
Allergic reactions are rare to the human milk.

Brings closeness to mother & child, decreases infant morbidity,
maternal health benefits (lactation amenorrhea, maternal weight loss,
and some cancer protection), economic and environmental benefits.

Benefits cognitive development, prevent childhood asthma, prevent
child from becoming overweight

Composition of Human milk- 60% whey (lactalbumin), 40% casins; 6-7%
energy provided

Breast milk supplies sufficient vitamin A, and a richer source of
vitamin E than cows milk; however not much of vitamin D provided.

Iron in human milk is small, approx. 50% in human and less than 1%
in cows milk. Cows milk provides 3xs the amount of calcium, and 6xs
the amount of phosphorus, and fluoride concentration is 2xs of human
milk.

Composition of Cows milk- 20% whey, 80% casein.; 20% energy provided

Cows milk contains adequate amounts of B-complex vitamins.

Casein forms a tough, hard to digest curd in the infants stomach,
whereas lactalbumin is soft, easy to digest curds.

Amino acids, taurine and cystine are higher in concentrations in
human milk than cows milk. These are especially important for
premature infants.

Lactose provides 40% of energy in human milk, and only 30% of
energy in cows milk.

Lipids provides 50% of energy in human and whole milk
Monounsaturated oleic acids are in both milks, Linoleic acid, as
essential fatty acids, provides 4% of energy in human milk and only
1% in cows milk.
The cholesterol content of human milk 10-20mg/dl compared
to 10-15mg/dl in whole cows milk. Less fat is absorbed from
cows milk than human milk ; lipase in the nonfat fraction of
human milk is stimulated by bile salts and contributes to the
hydrolysis of milk triglycerides.
Anti-infective factors- human milk and colostrum contains antibodies, not
present in infant formulas. Protects the infants gut from infection until 3mo
of age.
The iron-binding protein, lactoferrin in human milk deprives bacteria
of iron and thus slows their growth.

Lysozymes, which are bacteriolytic enzymes found in human milk,
destroy the cell membranes of bacteria after peroxides and ascorbic
acid that are present in human milk. Breast milk enhances the growth
of bacterium- lactobacillus bifidus, which produces an acidic
gastrointestinal environment that infers with the growth of certain
organisms. The incidents of infections are lower in breast-fed infants
than formula fed.

Formulas: regulated by FDA; cows milk, soy based formulas. Many may
choose to use a combination of both cows milk and breast milk.
Commercial formulas made from heat-treated nonfat milk or soy &
supplemented with vegetables, fats, vitamins, and minerals to form
approx similar composition of human milk.

Iron fortified formulas recommended for infants formula fed; however great
amounts of iron may cause constipation, loose stools, colic, and spitting up.

Soy formulas are similar to cows milk, but may place higher levels of
exposures of phytoestrogen and isoflavones than infants fed human
milk.
The amount of soy protein isolate used in formulas depends on
isoflavone content. For infants not tolerating cows milk soy-
based formula made from casein hydrolysates are used to meet
all nutritional requirements; such incidence are for infants of
vegetarian families, lactosemia or primary lactase deficiency,
allergic reaction to cows milk.

Whole milk- should not be fed to infants during the 1yr, due to
possible occurs of lower intakes of iron, linoleic acid , and vit E, and
excessive intakes of sodium, potassium, and protein. Cows milk may
produce a small amt of blood loss.
As well, low fat (1-2%) are not appropriate for the first yr








Formula preparation: can be prepared up to 24hrs and refrigerated;
should be warmed in a hot water bath prior to feedings. Any formula warmed
and not consumed at that feeding should be discarded, as well with any open
cans of formula should be covered, refrigerated, and used within 24hrs.

Variations of foods:
Ready-to-serve dry infant cereals (fortified with electrolytically reduced
iron), used to improved iron absorption. 3TBS provides 5mg iron or -1/3 of
infants requirements.

Jarred cereals, provide 7-9mg iron per 4.5oz jar

Strained jr vegetables and fruits provides CHO and various vit A and C.

Milk is added to creamed vegetables, with wheat incorporated into mixed
vegetables. All are excellent source of high-quality protein and heme
iron.

Puddings and fruit desserts, nutrient content varies but all contains excess
energy in form of sugar and modified cornstarch or tapioca starch.

Either salt or sugar should not be added to foods from infants.


Directions for home preparation of infant foods:
1. Select fresh, high quality fruits, vegetables, or meats
2. Be sure all utensils are cleaned thoroughly
3. Wash hands prior preparing foods
4. Clean, wash, trim foods in little water possible
5. Cook foods until tender in as little water as possible. Avoid overcooking,
which may destroy heat sensitive nutrients
6. Do not add salt or sugar. Do not add honey for younger than 1yrs old.
7. Add enough water for foods to be easily pureed
8. Strain or puree food using electric blender, a food mill, a baby processor
9. Pour puree into an ice cube tray and freeze
10. When frozen hard, remove cubes ad store into freezer bags
11. When ready to serve, defrost and heat in serving container the amount of
food that will be consumed at a single feeding







Feeding Patterns:
Starts @ 6mo, post weaning of breast milk or formula.

Development of feeding skills- at birth, coordinate sucking, breathing,
and swallowing through suckle liquids from breast or bottle.
During the 1
st
yr, infants develop head control, ability to move
into a sitting position, and ability to grippalmer and pincer.

Develop of mature suckling and rotatory chewing abilities and
progress from being fed to feeding themselves with fingers.

In the 2
nd
yr, they learn to feed themselves independently with
a spoon.

At 18mo, infants maturation proceeds and rate of growth slows
down, interest in food changes. Reduced breast-milk or
formula intake, as they become finicky with what and how
much they eat.

Addition of semisolid foods- between 4-6mo, munching movements begin,
introduction of strained foods.
Cereals started first with a spoon, oven-dried toast, arrowroot
biscuits, cheese sticks, mash potatoes, casseroles, and pastas.

Important to introduce one single food at a time.

Should consist of 2-7days intervals to enable any witness of allergic
reactions or intolerance to foods.

Including the ability to chew and swallow solids foods and use
utensils.
Learns to tolerate various textures and flavors of foods, eat
with fingers, and then feed themselves with a utensils.

At beginning of the meal, children are hungry and should allow to feed
themselves; when tired assistance can be provided.
Emphasis on table manners and fine motor points to enhance
maturity and developmental readiness.

Foods should be in form easily handled, meats cut into bite-size,
potatoes and vegetables mashed. Raw fruits and vegetables cut
so easily picked up; cups and dishes easily hold, and not able to
tip over easily.


Weaning from breast tissue or bottle to cup- ensure appropriate intake and
maintenance of growth.
Introduce cup at 6-9mo, and complete process when able to ingest
adequate amount of milk from cup at 18-24mo. Transition can consist
of breast to cup, or breast to bottle to cup. Either way done slow,
gradually for the comfort of the infant.

In weaning stages, infants need to learn many manipulative skills,

Early caries- prevent infants from bathing their teeth in sugar (sucrose or
lactose) throughout the day and night.
If infants are given sugar-sweetened beverages/juices in a bottle
during the day or at bedtime after teeth has erupted, the risk of caries
increase.

By promoting dental health, infants should be fed and burped and
then put to bed without milk, juice, or food. Juice should be limited to
4-6oz/day; and only offered from a cup.

Type of foods- simple/uncomplicated foods in child-size portions.
Younger than 6yrs may prefer mild-flavored foods. Snacks offered
between meals, fruit, crackers, cheese, dry cereal, fruit juices, milk.

Children 2-6 often prefer raw instead of cooked vegetables/fruits.

Infants offered foods that vary in textures and flavors.

To add variety, vegetables and fruits can be added to cereal feedings.

Provide proper selections and sizes of foods to prevent any disease
preconditions later in life, such as DM, cardiovascular disease, etc

Serving sizes- at 1yr infants eat 1/3-1/2 of amount an adult consumes,
3yrs increases to 1/2 , then by 6yrs 2/3 amount of an adult; due to the
small stomach of children compared to adults. To use as a guide,
1TBS/yr advances.

Forced feeding- should not be done, children need to learn their satiety levels.
Dont try to coax. Typically there is a reason why the child refuses
food.

To avoid under or overfeeding, parents should respond to cues for
hunger and satiety offered by the infant. A child fed snacks or given a
bottle too close to mealtime (within90mins) is not hungry & refuses.

Eating environment- young children should eat their meals distraction free,
and at the family table to learn table manners and further assist in
their developmental process. Family meals for child give a way for
parents to set a positive example to try new foods and be on a
supportive environment.

Satiety Behaviors in Infants:
4-12wks- draws head away from nipple, falls asleep, when nipple is
reinserted- closes lips tightly, bites nipple, purses lips, or smiles and
lets go

16-24wks- releases nipple and withdraws head, fusses or cries, obstructs
mouth with hands, pays more attention to surroundings, bites nipple.

28-36wks- changes posture, keeps mouth tightly closed, shakes head no,
plays with utensils, uses hands more actively, throws utensils

40-52wks- similar past behaviors with addition of sputters with tongue and
lips, hands bottle or cup to mother/father


























Nutrition In Childhood

Growth patterns:
Growth rate decrease after the first yr, due to the doubling within the first yr.
However, the length is increased 50% in the first yr, but then doesnt double
until the 4
th
yr.

Typically, weight increases 4-6.5# per yr until age 9-10yrs. Height increases
increments average 6-8cm per yr from 2yrs to puberty onsets.

Growth is steady and slow during pre-school and school-age years.; there can
be a period of no growth followed by a rapid growth spurt. During the
growth period there can be struggles with food intakes and appetite levels.

Fat generally decreases during early childhood yrs, reaching a minimum
between 4-6yrs.

Children can experience adiposity rebound, or increase in body weight prior
puberty. Early rebound is associated with increase adult BMI. Boys have
more lean body mass per height than girls. Females have higher weight as fat
than males, even in pre-school yrs, but differences in lean body mass and fat
do not become significant until teen yrs.

Children generally maintain their height and weights in the same growth
channels during pre-school and childhood yrs, however not really
established until 2yrs.

Catch-up growth- usually for children who are recovering from illness/disease, or
undernutrition, which their growth was ceased or slowed.
Period during which the body strives to return to the childs normal
growth channels.

The degree of growth suppression is influenced by timing, severity,
and duration of the cause, such as celiac disease, cystic fibrosis.

Energy, protein, vitamin A, iron, and, zinc requirements are increased
during this period, amounts depends on the childrens ideal height
and weight for age. Once the child caches up to growth, appropriate
dietary management is reassessed & changes.






Assessing growth- complete assessment of anthropometrics (length, height, weight,
percentiles, BMI, comparison to CDC growth charts from birth to current
times to see if there is a significant change to be corrected)
Acknowledges any pre-conditions to obesity, acute illnesses,
undernutrition, undiagnosed chronic conditions, significant emotional
or family problems.

Nutrition requirements:

Energy- 45-65% as CHO, 30-40% as fats, and 5-20% as proteins for 1-3yrs &
45-65% CHO, 25-35% fats, and 10-30% proteins for 4-18yrs;
determined by the metabolism rate, rate of growth, and energy
expenditure 13-15kcal/cm for 2-5yrs, 13-14kcal/cm for girls 16-
17yrs, and 16-17kcal/cm for boys 6-11yrs .

Protein- decrease need from 1.1g in early childhood to .95-.8g in later
childhood.
Protein intake range from 5-30% based on age & conditions.

Deficiencies are uncommon due to societies large influence in
protein sources. However, children who are at increase risk of
inadequate protein intake are those on a strict vegan diet,
multiple food allergies, or who have limited food selections
because of fad diets, behavioral problems, or inadequate access
to foods.

Iron- can be at risk for anemia. Rapid growth period of infancy is marked by
an increase in hemoglobin and total iron mass.

Children with prolonged bottle feedings, and those of Mexican
American decent are at greater risk of deficiency. Recommended
intakes factor in absorption rate and quality of iron in foods,
especially plant based selections.

Calcium- 500mg/day for 1-3yrs, 800mg/day for 4-8yrs, and 1300mg/day for
9-18yrs; required for mineralization and maintenance of growing
bones in children.

Actual need depends on individual absorption rates and dietary
factors such as quantities of protein, vitamin D, and phosphorus. Milk
and dairy sources are primary sources; ones who have limited supply
or allergies to products have poor mineralization.




Zinc- essential for growth, a deficiency results in growth failure, poor
appetite, decreased taste acuity, and poor wound healing.
Best sources are meats and seafood. It is not uncommon for
children to have low intakes, however marginal deficiency
since in pre-school and school-age children and children from
middle & low-income families.

Vit D- required for calcium absorption and deposition of calcium in the
bones; rickets is a bone disease resulting from too little vitamin D.

Mostly formed from the sunlight, children of topical climates may
need none to 2.5mcg/day of vit D. Vit D fortified milks is a primary
source, other sources are yogurts, cheese, and selective breakfast
cereals are fortified with vit D.

Vitamin-mineral supplementation- approx. 50% pre-school children are given
supplements (M/V with iron, fluoride 6mo-16yrs), however, it
doesnt necessary fulfill nutrient needs as well as whole foods.

Beneficial for children who are at risk for inadequate nutrition, such
as deprived families, parental abuse or neglect, anorexia, fad diets,
chronic diseases- cystic fibrosis, crohns & celiac disease, or renal or
liver diseases.

Educate parents on ways to prevent excessive amounts of nutrient
consumption from vitamin-supplements verse whole foods

Herbal products are becoming common, especially for children with
Downs syndrome autism, or cystic fibrosis. Educate caregivers on
affects, any absorption interactions, and/or efficacy/safety of the
herb.












Intake patterns: Children mostly have inadequate intakes of calcium, iron, zinc,
vit B6, vit E, magnesium, and vit A.
Especially over the last few yrs food patterns have changed to more of
a convince foods lifestyle than family meals and bring lunches from
home.

Sugar and sodium consumption has increased, leading to 75%
children meeting recommendations towards higher cholesterol.

Changes in food consumption are reflected in nutrient intakes. Seen
by childs 1
st
b-day, milk consumption begins to decline, next yr
vegetable intakes decline, where as intakes of cereals, grains, and sweets
increase.

Factors affecting food intake:
Family environment- food attitudes, family meals, and income status for
available sources, food preferences: children learn behaviors from
parents/guardians.

Societal treads- eating 1 or more meals outside the home/day, daily time
constraints, family meals, parents and childrens busy schedules
between work, school, sports, activities. Children typically get one
nutritious meal while in school due to the standards of USDA school
lunches. While younger school age children less than 5yrs are on
WIC/food stamps.

Media Messages- marketed mainly to children with bright colors, enlarge
juicy pictures, toys included, etc. With changing yrs, children have
more TV & Internet access which proposes them to further
advertisements, and inactivity lifestyles; all of which contributes to
obesity, increase dental caries, and illness/diseases earlier on.

Peer influence- influences foods attitudes and choices, dietary changes in
trying certain diets or food groups.

Illness or disease- causes children to have decrease appetite and limited food
intake.
Viral or bacterial infections are short-lived, but require
increase fluids, proteins, energy, and vitamins. Chronic illness
such as asthmas and cystic fibrosis, and renal disease are a
challenge to provide the children with sufficient nutrients for
growth.



Feeding preschool & school-age children:
Fun, creative, bright, and a variety of foods to enhance intake

Teach the child the importance of each food for their growth.
Some maybe picky eaters, but get then involved with
cooking/preparing meals or snacks; while providing positive
reinsurance for trying new foods. Eating in a social group for
meals/snacks.

Foods can be used as daily experiences for toddles and pre-schoolers and
promote the development of language, cognition, and self-help behaviors
(labeling, describing size, shape, colors; sorting, assisting in preparation, and
tasting).

Nutritional concerns:
Overweight/obese

Underweight & FTT

Iron deficiency

Allergies

Dental caries

ADHD- results in excessive motor activity, impulsiveness, short attention
span, low tolerance for frustrations, and an onset before 7yrs old.
Various dietary factors may be caused from artificial flavors
and colors, sugar , altered fatty acid metabolism, and allergies.

A common diet is Feingold diet, provides no sugar, allergies
eliminated diets, and supplements of vitamins and essential fatty
acids.












Autism spectrum disorder- diagnosed with impairments in three behavior
categories of social interactions, verbal/non-verbal communication,
and restrictive or repetitive behaviors. Affects the childs nutritional
intake and acceptance to foods, increase hypersensitivities (textures,
temperatures, color, and smell), differcult in making transitions.

Typically children refuse fruits and vegetables, and maybe are
interested in taking vitamin-mineral supplements.

Nutritional interventions consist of gluten-free/casein-free, and
allergy-free diets; along with providing essential fatty acid
supplements, large doses of vitamins, and alternative therapies.

Behavioral interventions are to accept foods within home and school.

Preventing chronic disease:
Decrease amounts of dietary fat , to prevent any poor cardiovascular
health, and or diabetes risks

Ensure recommended amounts of calcium, to provide adequate bone
health and prevention of obesity

Increase amounts to fiber intakes to improve recognition to satiety
levels and GI health.

Increase amount of physical activity for overall medical health and
bone/muscle strength. Set a positive examples and importance of
activity young enough before teens and adult yrs for the prevention o
illness/diseases.
















Nutrition in Adolescence- (12-21yrs old)

Growth & development: changes in cognitive and emotional development, also
peer influences.

Puberty- rapid growth and development for sexual reproduction increase
hormones- estrogen, progesterone, and testosterone. Changes to body
image and voice.

Sexual maturity rating (tanner stage), access degree of maturation.
Males based on genital and pubic hair; females based on breast and
pubic hair development, also the begin of menstruation (avg 12.4yrs,
different based on racial backgrounds, genetics, and physical activity
level)

5 Stages, first begin of puberty development, to last stage
marking the completion of physical growth and development.
























Changes to cognitive & emotional development- 3 periods:

Early adolescence: 13-15yrs
Preoccupied with body size, shape, image

Continuation of trusts & respect for adults as authority figures

Strong influences of peers, especially around image and appearance

speaking about age 14yrs

Desire for autonomy but still obtaining parental approval for
decisions, and parental security when experiencing stress

Expanded cognitive ability, abstract reasoning

Increase in money spending resulting in more independence
purchasing power, snacks, meals, and clothing

Middle adolescence: 15-17yrs
Persistence from peer groups influences; teens influenced by fewer
individuals with whom they are closely bond

Trust in adult authority and wisdom decreases

Body image issues become les pronounced as adolescence become
more comfortable in his or her adult like body shape and size

Social, emotional, and financial independence becomes more
pronounced, leading to increase independence decision making
related to food and beverage intakes

Significant cognitive development occurs as abstract reasoning is
nearly complete and egocentrism decreases












Late adolescence: 18-21yrs
Abstract reasoning fully developed; however, teens may still revert
to less complex thinking patterns when stressed

Future orientation, which is required to understand link between
current behaviors and chronic health risks develop

Social, emotional, financial, and physical independence from family
occurs as teens leave home to attend college or live on their own in
seeking full-time employment.

Development of core set of values and beliefs that guide moral,
ethical, and health-related decisions.



























Nutritional requirements:

Calories- females require 2200 Cal./day and males 2500-3000.

Protein- females 0.8g/kg/d males 1.0g/kg./d (30% of caloric intake) weight lifters
only 1.6-1.7 mg/kg/d. Many teens meet or exceed this level, including
vegetarians.

Fats- 30% of daily calories. Most adolescents get enough fats. Teenagers should be
taught to read labels and learn about fat content of foods.

Calcium- The majority of bone mass deposition occurs during adolescence. Daily
requirement 1500 mg/day. Sources include dairy products, calcium
enriched orange juice, green leafy vegetables, sardines, soymilk, tofu or
antacid tablets.

Iron- requirements are high during adolescence because of growth. Requirement
higher in menstruating females. Good sources include meats, green
vegetable, cereals fortified with iron, fish, poultry, eggs, and nuts.

Inadequate iron intake/absorption/stores:
o Vegetarian diets, especially vegan diets
o Low meat, fish, poultry, or iron-fortified foods
o Low intake of ascorbic acid foods
o Frequent dieting or restrictive eating
o Chronic or significant weight loss
o Meal skipping
o Substance abuse
o History of iron deficiency anemia
o Recent immigration from developing country
o Special health care needs

Increase iron requirements/losses:
o Heavy/lengthy menstrual periods
o Rapid growth
o Pregnancy (recent or current)
o Inflammatory bowel disease
o Chronic use of ASA, NSAIDS (ibuprofen), or corticosteroids
o Participation in endurance sports (long-distance running, swimming,
cycling)
o Intensive physical training
o Frequent blood donations
o Parasitic infections


Zinc- 12-15 mgs/day. Found in meats, eggs, seafood, and dairy products

Fiber-20-25 grams/day. Found in fruits, vegetables, grains, beans, and cereals.

Vitamins-most commonly adolescents are deficient A, B6, E, D, C, and folic acid.
Usually, adolescents who are eating normal daily requirements of
nutrients are not deficient in vitamins. Vitamin supplements may be added
to meet requirements.

Folic Acid- 300mcg/day for 9-13yrs, 400mcg/day for 14-18yrs. Required for later
adolescence to support lean body mass and provide females of
reproductive yrs as a prevention measure against neural tube deficits.
Sources of food are dark green leafy green vegetables and citrus fruit, as
well as fortified grain products.

Vitamin D 400 IU/day. Found in fortified milk and cereal, egg yolks. Prevalence of
deficiency is 14%; 20 times higher in non-Hispanic, black adolescents, twice
as high in females and inversely related to weight (using the definition of
vitamin D deficiency as a serum level of 25-hydroxy vitamin D <20 ng/mL)

Food habits & Eating behaviors: Nutrients deficient causes
Dieting & body image- lead to eating disorders or disordered eating

Irregular meals & snacking

Increase use of fast, convenience, vending machine foods- based on
geographic locations and timing with busy schedules

Lack of family meals

Influences of media & advertisements through papers, word of mouth,
radio, TV, internet, etc












Teen-Friendly Health Snacks:
o Pudding made with skim milk

o Glass of skim milk with TBS chocolate or strawberry syrup

o Soft pretzels topped with mustard or salsa

o Sliced apples dipped in peanut butter or fat-free chocolate / caramel
dip

o English muffin mini-pizzas, topped with tomato, sauce, mozzarella
cheese)

o Air-popped popcorn

o Peeled & sectioned oranges/clementines

o Hummus with pita bread

o String cheese

o Baked tortilla chips with bean dip or salsa

o Baked potato, topped with salsa, yogurt, or fat-free sour cream

o Graham crackers, animal crackers, containing no saturated/trans fat

o Frozen yogurt/juice bars

o Trial mix (dried fruit with nuts & seeds)

o Fruit drink spritiz ( cranberry juice & seltzer water)

o Low-fat granola bars

o Mini-rice cakes

o Sandwich wraps with slices of turkey, cheese, and tomato







Nutrition screening, assessment, & counseling:
Obtain 24hr recall & food preferences

Screenings based on BMI, height, diets, food allergies, calories restriction,
and energy expenditures

Assessment evaluation based on medical, psychosocial, and socioeconomic
history (chronic diseases, substance use, depression, disordered eating,
pregnancy/lactating), growth & development, typical food consumptions,
amount physical activity, and routine screening/laboratory testing
(cholesterol, HTN, DM, anemia)

Social Situations:
Vegetarian dietary patterns- relatively provides adequate nutrients,
however, vegan diets limit adequate amounts of iron, B12, calcium, vit
D, and zinc.

Daily food intake for vegetarians:
9-11: Bread, grains, cereal
2-3: Legumes
4-5: Vegetables
4: Fruits
1: Nuts, seeds
3: Milk, yogurt, cheese
: Eggs (limit 3/wk)
4-6: Fats, oils (added)
6-9: Sugars (added)

Eating disorders

Over weight or obese-- Cardiovascular, metabolic syndrome, DM occurrences

Hyperlipidemia & HTN-- Cardiovascular, metabolic syndrome, DM
occurrences











Physical activity & sports nutrition
Young adolescence is greatest risk of dehydration because they
produce more heat production during exercise but have less ability to
transfer heat from muscles to skin.

Sweat less, which decreases their capacity to dissipate heat through
evaporation of sweat. Medical conditions, such as bulimia, diarrhea,
cognition heart-disease, DM, gastroenteritis, fevers, or obesity may be
placed at increase risk of heat-related illnesses due to excessive fluid
lost.
Those with anorexia, cystic fibrosis, developmental disabilities,
and/or kidney disease maybe less liking to consume sufficient
fluid intake; placing them at risk to dehydration.

Athletes participating in competitive weight categories at increase
risk of disordered eating behaviors. A concern among females is the
development of Female Athlete Triad, low body fat levels,
amenorrhea, and osteoporosis.
Conditions may result in premature bone loss, decrease bone
density, increased risk of stress fractures, and eventual
infertility.

Sports nutrition education for teens should be focus on benefits on
healthy eating, such as energy, essential fats, and physical
performance.

Pregnancy- has higher nutrient requirements; with teens typical non-
nutritional diets there are greater risks of deficiencies. Weight gains
are individual based on persons body image/height/BMI.

















Dietary Enhancements: Functional Foods-- Plant-based

A way to enhance heath, maintaining wellness towards choosing fewer
calories, multiple benefits, and risk-reducing foods.
Helps to lower blood pressure, control blood sugar levels

Serves as a antioxidant, towards promoting GI health,
detoxification enzymes in liver

Foods include, whole grains, yogurt, nuts, soy, legume, and fruits and
vegetables along with lower-fat foods (oils from fish, plant oils: olive,
canola, soy, corn, sunflower, peanut) and fortified or supplemented
products (flax seeds, certain spices).

Phytochemicals/phytonutrients- biological active and natural in plant foods,
act as bodies natural defensive mechanism for protection against
microbial invasions or infections. Provides color, aroma, and flavor.

Flavonoids & carotenoids- 2 of 2000 plant pigments variations.

Soy, many benefits, reducing heart disease, certain cancers, and
vasomotor symptoms (hot flashes). Consist of no cholestrol due to being a
plant, source of isoflavones (a phytoestrogen plant estrogen).
Use to displace animal protein and help lower intake of saturated
fats but not recommended as a therapy to reduce HDL cholesterol or
other CVD risk factors.



















Nutrition in Aging

Most organ systems lose about 1% of their functioning ea yr starting at 30.

Physiologic changes:
o Body composition- sacropenia onsets

o Sedentary lifestyle

o Sensory losses- loss of appetite, and/or craves sweet & salty foods

o Oral health- dentures, tooth loss, dry mouth, polypharm.

o Gastrointestinal- dysphasia from weak oral muscles, constipations,
decrease stomach acid production can produce limited to no B12
absorption, mimicking Alzheimers, fatigue, dementia, confusion,
tingling/weakness in arms & legs

o Cardiovascular- heart disease & CVA risk, changes in arterial wall, decrease
max HR, slowed ventricular relaxation, decrease responsiveness to B-
adrenergic stimuli, increase left ventricle muscle mass

o Renal disease- yields to inability to excrete concentration or dilute urine,
delay response to an acid load. Functioning impacted by dehydration,
diuretic use, and medications. Glomerular filtration rate declines by 8-
10ml/min/1.73m2/decade after 30-35yrs old

o Neurologic function- decline in gait, cogitation, steadiness, reactions,
coordination. Cause from neurons death within a pathology effect;
other cause is decrease in surface area from tangling of
axons/dendrites

o Depression

o Pressure ulcers/wound healing/ thinnest of skin- malnutrition impacts
healing. Proper protein and nutrients required

o Frailty & FTT

o Hearing & Eyesight

o Immunocompetence




Supportive Services:
o Older American Act nutrition program

o USDA Food Assistance program

o Food Stamp program

o Food Stamp nutrition education program

o Commodity supplement food program

o Seniors Farmers Market nutrition program

o Child & Adult Care food program

o Emergency Food Assistance program

o Food Distribution program on Indian Reservations

o Medicaid & nutrition services

o Assisted living facilities & Skilled nursing facilities: