LIFE CYCLE NUTRITION: PREGNANCY AND LACTATION

During pregnancy all women need more food, a varied diet, and micronutrient supplements. When energy and other nutrient intake does not increase, the body’s own reserves are used, leaving a pregnant woman weakened. Energy needs increase in the second and particularly the third trimester of pregnancy. Inadequate weight gain during pregnancy often results in low birth weight, which increases an infant’s risk of dying. Pregnant women also require more protein, iron, iodine, vitamin A, folate, and other nutrients. Deficiencies of certain nutrients are associated with maternal complications and death, fetal and newborn death, birth defects, and decreased physical and mental potential of the child.

Lactation places high demands on maternal stores of energy, protein, and other nutrients. These stores need to be established, conserved, and replenished. Virtually all mothers, unless extremely malnourished, can produce adequate amounts of breastmilk. The energy, protein, and other nutrients in breastmilk come from a mother’s diet or her own body stores. Women who do not get enough energy and nutrients in their diets risk maternal depletion. To prevent this, extra food must be made available to the mother. Breastfeeding also increases the mother’s need for water, so it is important that she drink enough to satisfy her thirst.

Body Composition Changes during Pregnancy

Following conception and continuing until parturition (childbirth), many metabolic, anatomic, hormonal, psychologic, and physiologic changes take place in the mother. This chapter focuses on those most affected by or affecting nutrient intake.

Hormones of Pregnancy

There are numerous steroid hormones, peptide hormones, and prostaglandins that influence the course of pregnancy. Some of them, such as the placental hormones human placental lactogen and human growth hormone, are produced only during pregnancy. Others, including insulin, glucagon, and thyroxine, are present in altered amounts compared with the nonpregnant state and have profound influences on metabolism throughout gestation.

Progesterone and estrogen have a particularly strong influence on pregnancy.

The multiple roles of progesterone and estrogen in normal human pregnancy. After implantation ofan embryo in the uterus, the trophoblast (the future embryo and placenta) secretes human chorionic gonadotropin (hCG) which maintains the corpus luteum until the placenta, at about the seventh week of pregnancy,begins producing the sex hormones progesterone and estrogen.

The action of progesterone promotes development of the endometrium and relaxes the smooth muscle cells of the uterus. This relaxation serves both to help the uterus expand as the fetus grows and to prevent any premature contractions of the uterus.

Hormone levels released from the corpus luteum and placenta during pregnancy. The width of the arrows suggests the relative amounts of hormone released;hCG (human chorionic gonadotropin) is produced solely by the placenta. Synthesis of progesterone and estrogen shifts during pregnancy from the corpus luteum to the placenta.

The same effect also influences other smooth muscle cells, such as the gastrointestinal (GI) tract. The resulting slowing of the GI tract during pregnancy may increase the absorption of several nutrients, most notably iron and calcium. One perhaps annoying consequence of this decreased gut motility is the promotion of constipation.

Progesterone causes increased renal sodium excretion during pregnancy. The body compensates for this sodium-losing mechanism by increasing aldosterone secretion from the adrenal gland and renin from the kidney. Sodium restriction during pregnancy, once thought to prevent hypertensive disorders of pregnancy, is actually harmful because it reduces plasma volume and cardiac output.

Estrogen promotes the growth of the uterus and breasts during pregnancy and renders the connective tissues in the pelvic region more flexible in preparation for birth.

Metabolic Changes

There are profound changes in maternal metabolism during pregnancy, and successful adaptation to these changes is necessary for a favorable pregnancy outcome.

The basal metabolic rate (BMR) rises during pregnancy by as much as 15% to 20% by term. This increase is caused by the increased oxygen needs of the fetus and the maternal support tissues. There are alterations in maternal metabolism of protein, carbohydrate, and fat. The fetus prefers to use glucose as its primary energy source. Changes occur in maternal metabolism to accommodate this need of the fetus. The adaptation allows the mother to use fat as the primary fuel source, thus permitting glucose to be available to the fetus.' Increased macronutrient and micronutrient intake by the mother during pregnancy ensures that these increased metabolic needs are met.

Anatomic and Physiologic Changes

Plasma volume doubles during pregnancy, beginning in the second trimester. Failure to achieve this plasma expansion may result in a spontaneous abortion, a stillbirth, or a low birth weight infant. One of the results of this increase in plasma volume is a hemodilution effect. In other words, measured components in the plasma such as hemoglobin, serum proteins, and vitamins will appear to be at lower levels during pregnancy because there is a greater volume of solvent (the plasma) relative to concentrations of solute (the components). Cardiac hypertrophy occurs to accommodate this increased blood volume, accompanied by an increased ventilatory rate.

In the kidneys, the glomerular filtration rate (GFR) increases to accommodate the expanded maternal blood volume being filtered and to carry away fetal waste products. As a result of this increase in GFR, small quantities of glucose, amino acids, and water-soluble vitamins may appear in the urine. Although minor losses may be acceptable, a woman who excretes large amounts of protein may experience a more serious problem called pregnancy-induced hypertension, which needs strict medical monitoring.

As previously mentioned, progesterone may slow GI motility during pregnancy, leading to constipation, heartburn, and delayed gastric emptying. In late pregnancy, these problems may be exacerbated by the weight of the uterus and fetus as they compress the abdominal cavity.

Weight Gain, in Pregnancy

1st Trimester

Weight gain should be minimal in the first trimester (0.5 to 2.0 kilograms or 1.1 to 4.4 pounds). If you lose or gain a significant amount of weight in the first trimester (more than five to 10 per cent of your pre-pregnancy weight), talk with your healthcare provider for support.

2nd Trimester

During the second trimester your healthy weight gain should be steady and gradual. Averaging around 0.2 to 0.5 kilograms (0.5-1.0 pound) per week. If you're gaining more, see the guidelines in and compare your eating habits.

3rd Trimester

Weight gain should remain steady and gradual during your third trimester. The average weight gain is around 0.2 to 0.5 kilograms (0.5-1.0 pound) per week.

There are three components to maternal weight gain:

(1) maternal body composition changes including increased blood and extracellular fluid volume;

(2) the maternal support tissues such as the increased size of the uterus and breasts; and

(3) the products of conception, including the fetus and the placenta. Inadequate weight gain by the mother during pregnancy suggests she may not have received the proper nutrients during pregnancy. Poor weight gain may then lead to intrauterine growth retardation in the infant. Infants born small for gestational age (SGA) or low birth weight are more likely to require prolonged hospitalization after birth or be ill or die during the first year of life. Additionally, infant mortality rate, which in part reflects maternal weight gain, is regarded as one measure of a country's health and well-being. Although the 1998 infant mortality rate for the United States continued an all-time low first reached in 1996 (7.2 per 1000 live births),4 it still remains far greater than other developed countries. Infant mortality rates are higher among African Americans (14.3/1000 in 1998) than among Caucasians.

There is strong evidence that the pattern of weight gain is just as important as the absolute recommended weight gains shown in Table 11-1. Failure to gain adequately during the second trimester of pregnancy is associated with poor infant birth weight, even if the net gain falls with the recommendations A balance must be struck regarding weight gain during pregnancy. Although women who are underweight or normal weight (as defined by body mass index [BMI]) are counseled to eat sufficiently to promote adequate gain, caution must be observed in counseling women who enter pregnancy overweight or obese.

Overweight and obese women should gain enough weight to support the fetus and maternal support tissues but without increasing total body fat. There are increased risks for operative delivery, increased maternal postpartum weight, gestational diabetes, and other long-term health consequences when maternal weight goes beyond the guidelines, particularly among women who are obese before pregnancy.6'7 In addition, there may be subpopulations such as minorities and low-income women who need special guidance regarding weight gain during pregnancy.

Nutritional Needs of Pregnancy

Pregnancy is the most nutritionally demanding time of a woman’s life. Your body needs enough nutrients every day to support the growth of your baby and the maintenance of your own body. All the nourishment this developing baby needs comes from you, either through the foods you eat or the supplements you take.

Pregnant women need more essential nutrients than other women. From the beginning of the second trimester until delivery, your body needs an additional 300 calories each day to support the growth of your baby. It is important to eat the right foods every day since tissues and organs develop during certain weeks of your pregnancy. Your own health depends on your diet, too. While your body is supplying the nutrients your baby needs, your body still needs the same nutrients as before you were pregnant.

My Pyramid helps you choose healthy foods to meet your needs. Increase your intake of nutrient-dense foods. Nutrient-dense foods are packed with more nutrients for the calories than other foods that are mostly calories with few other nutrients. Nutrients are also called vitamins and minerals.

By following MyPyramid recommendations based on age, sex, and activity level while adding the additional 300 calories per day at the start of the second trimester, you can get the nourishment you need.

Protein is needed for the buildup of your muscles, uterus, breasts, blood supply, and baby’s tissues. Low protein intake is related to smaller-than-average weight babies who may have health problems. Pregnant women need around 60 grams of protein per day.

Folate is a vitamin that is required to build protein tissues. Low folate levels are linked to birth defects, such as spina bifida. These defects form early in pregnancy, often before women know they are pregnant. It is important to eat enough foods high in folate like broccoli, dark green vegetables, and oranges both before and during pregnancy. The dietary reference intake for folate is 400 milligrams per day.

Substantial research has demonstrated that folate is important for the prevention of neural tube defects (NTDs) such as spina bifida and anencephaly, one of the most common congenital malformations in the United States.

Approximately 2500 to 3000 infants are born with NTDs each year in the United States, with an equal number likely lost to pregnancy termination and additional unknown numbers of spontaneous abortions. The U.S. Public Health Service and the American Academy of Pediatrics now recommend all women of childbearing age who are capable of becoming pregnant receive a daily intake of 400 meg of synthetic folic acid (from vitamin supplements, fortified grains, and other foods).

Although fortification has been implemented, education continues to be needed to encourage awareness of folic acid intake by women of childbearing age. During pregnancy the Dietary Reference Intakes (DRI) increase to 600 meg dietary folate equivalents (DFE) per day.

Sources of Folate

· Liver

· Dark green leafy vegetables

· Nuts

· Citrus fruits

· Dried beans and lentils

· Enriched breads or cereals

· Eggs

Calcium is needed by your baby for strong bones. If calcium is not supplied by the mother’s diet, calcium is taken from the mother’s bones for the baby. The dietary reference intake for calcium is 1,000 milligrams per day or 1,300 milligrams per day for women under 18 years of age.

Low Zinc levels during pregnancy can cause long labor and small babies who may have health problems. The dietary reference intake for zinc is 11 milligrams per day or 12 milligrams per day for women under 18 years of age.

Iron deficiency is common in pregnant women. Both mother and baby need iron for their developing blood supplies. A developing baby also stores iron for use after birth. This increases the mother’s iron needs. It is practically impossible to get enough iron from food. Doctors usually recommend supplements. The dietary reference intake for iron is 27 milligrams per day for all pregnant women.

Sources of Iron

• Lean red meats and poultry
• Dried beans and lentils
• Enriched breads or cereals
• Nuts and peanut butter
• Eggs
• Dark green leafy vegetables
• Dried fruits

A good diet takes planning.

Pregnant women should make sure to include:

· Enough calories for adequate weight gain.

· A variety of foods from each food group, with limited use of the oils and solid fats group.

· Regular meals and snacks.

· 30 grams of dietary fiber every day.

· 8 or more cups of water each day.

· Salt to taste.

· No alcoholic beverages, including beer.

· Prenatal vitamin once a day, if prescribed by your doctor.

No one can guarantee a baby will be born healthy and strong. However, these are steps mothers-to-be can take to make the best baby possible. Nothing offers greater benefits to mother and baby than good nutrition.

Guide to Good Eating During Pregnancy

Tips to Remember:

· Eat a variety of foods.

· Choose foods with a lot of fiber—fruits, vegetables, dry beans, whole grain breads and cereals, and other whole grain products.

· Exercise in moderation on a regular basis (ask your doctor).

· Drink plenty of fluids (64 ounces per day or eight, 8-ounce glasses)

· Eat 3 to 5 meals and snacks per day.

· Pregnancy increases the need for calories and most nutrients. Starting with the second trimester, you need to increase your normal calorie level by 300 calories to provide the extra energy your body needs. Remember, this is not a lot of food. 300 calories is equal to a small snack, such as a half of a peanut butter and jelly sandwich and a glass of 1% milk.

· The amount of suggested weight gain depends upon your weight before pregnancy (ask your doctor).

Weight Before Pregnancy	Suggested Weight Gain
Normal Weight (BMI 20–24)	25–35 pounds
Underweight (BMI < 20)	28–40 pounds
Overweight (BMI 25–29)	15–25 pounds
Very Overweight (BMI > 30)	~15 pounds

Recommended Servings^*

*Based on a 2000 calorie diet. Your needs may vary depending on age, sex, and activity level.

Dairy Group—3 cups per day; be sure to choose lower fat selections

Count as 1 cup: 1 cup (8 ounces) 1% or skim milk; 1 cup low-fat yogurt; 2 cups low-fat or fat-free cottage cheese; 1Ѕ cups low-fat or fat-free ice cream; 1Ѕ ounces of low fat hard cheese (cheddar, mozzarella, Swiss, or parmesan); 1/3 cup shredded cheese; 2 ounces processed cheese (American); 1 cup pudding (made with milk).

Meat and Meat Alternatives—5.5 ounce equivalents (or the amount of a food that has a similar nutrition value as 5.5 ounces of meat)

Count as 1 ounce equivalent: 1 ounce lean meat, fish, or poultry; 1 egg; 1 slice lunch meat; 1 tablespoon peanut butter; 1/4 cup cooked kidney, pinto, or garbanzo beans.

Fruit Group—2 cups

Count as 1 cup: 1 cup (8 ounces) 100% juice; 1 large banana or orange; 1 small apple; 1 cup canned fruit. Include one Vitamin C source such as an orange or orange juice every day.

Vegetable Group—2.5 cups

Count as 1 cup: 1 cup cooked vegetables; 2 cups raw leafy vegetables; 1 cup (8 ounces) 100% juice. Include one serving of a dark green leafy vegetable every day.

Grain Group—6 ounce equivalents (or the amount of a food that has a similar nutrition value to 6 ounces of a grain)

Count as 1 ounce equivalent: 1 slice 100% whole grain bread; 1 cup whole grain, ready-to-eat cereal; Ѕ cup cooked cereal, rice, or pasta, Ѕ “mini” bagel, 1 small tortilla, 6 inches in diameter; 1 pancake, 4Ѕ inches in diameter.

Oils and Solid Fats—use sparingly

Common portions: 1 tablespoon corn, safflower, or cottonseed oil; 1 tablespoon margarine; 1 tablespoon mayonnaise; 1 ounce nuts; and 4 large olives.

Most cakes, pies, cookies, soft drinks, sugar, honey, candy, jams, jellies, gravies, butter, and sour cream have either an oil or solid fat and may be loaded with simple sugars. Eat them in moderation; save them to eat only if you need extra calories after eating the basic needed foods.

MyPyramid
A Guide to Daily Food Choices when Pregnant
Oils and Solid Fats	Use sparingly
Milk, Yogurt, and Cheese Group	3 cups
Vegetable Group	2.5 cups
Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts Group	5.5 ounce equivalents
Fruit Group	2 cups
Bread, Cereal, Rice, and Pasta Group	6 ounce equivalents

Expectant Mother's Nutrition Needs During Pregnancy and Lactation (Breastfeeding)

Prenatal Dietary Needs

In the United States, approximately 300-500 women die every year from giving birth, 11% of infants are born too early, 7.4% have low birth weight, and 7 of every 1000 live births die within the first year of life. These are stunning statistics; however, there are many things an expectant mother can do to reduce these statistics. (Grosvenor & Smolin, 2006)

Expectant Mother's Weight

During the 40 weeks the mother carries the fetus, the fetus receives all the nutrients and nourishment from the mother via the placenta; so in essence, the mother is eating for two: she is eating for her own nutritional health, and the health of the child she carries. During pregnancy, a woman's body undergoes significant changes that cause weight gain: blood volume increases 50%, vital organs (heart, kidneys, and lungs) must work harder to eliminate waste and deliver oxygen and nutrients, body fat increases to sustain energy during later pregnancy, the uterus grows, and muscles and ligaments relax to allow growth of the fetus; all these changes require different nutrients. (Grosvenor & Smolin, 2006)

The weight a woman gains during pregnancy is vitally important, too much or too little can negatively alter the mother and child's health; too little weight gain raises the risk of a low-birth-weight, and gaining too much weight raises the risk of gestational diabetes, high blood pressure, difficult delivery, cesarean section, and a larger-for-gestational-age baby. A healthy woman of normal weight are recommended to gain 25 to 35 pounds; an underweight woman is recommended to gain up to 40 pounds; and an overweight woman is recommended to gain only 15 to 25 pounds during pregnancy. This 25 to 35 pound weight gain is not all body fat; it amounts to roughly a seven to eight pound fetus, two pounds of amniotic fluid, one to two pound placenta, two pound increase in uterine weight, three to four pounds increase in blood volume, two pounds increase of breast tissue, four pounds of extracellular fluids, and four to eleven pounds of body fat. Most of this weight gains is lost during the first year following pregnancy.

A woman's diet during pregnancy and lactation affects her health and the health of her child.

Takeaways

· The mother's blood volume increases 50% during pregnancy.

· Too much or too little weight gain during pregnancy can affect the mother and child.

· Dieting is not recommended during pregnancy, not even for overweight and obese mothers.

Did You Know?

In the US, roughly 300-500 women die yearly from giving birth, 11% of infants are born too early, 7.4% have low birth weight, and 7 of every 1000 live births die the first year. There are many things an expectant mother can do to reduce these statistics.

Mother & Child Master PostNatal Formula

Multiple Vitamin and Mineral

During pregnancy, a woman’s body undergoes the most profound change it will ever experience. As gestation evolves, an energy called Kidney “Essence” passes from mother to fetus. During labor and delivery, an enormous amount of this energy is transferred.

After delivery, the newborn child is, for at least the first four to six months, completely dependent upon mother’s milk or formula substitutes for food. Studies show that children who are breastfed for at least two years do better in virtually every aspect of development than those who are not. While the quality of any mother’s milk is better than store bought replacements, not all milk is created equal. To have the strongest milk possible, and to regain her own strength as quickly and completely as possible, a woman must consume foods that restore this “Essence” energy. Common table foods simply cannot accomplish this

Mother & Child – Recovering While Nursing

Mother & Child provides higher potencies of vitamins and minerals than Two ‘n’ Only, because the child is now separated from the mother, and gets only minute amounts of these nutrients from the milk. More importantly, it provides the green foods to energize the body as a whole, and a wondrous combination of Superior Tonic Herbs to help restore the “Essence” spent during pregnancy and delivery. A great deal of “Essence” is also passed through the milk, so that renewing it in the mother helps deliver it to the child.

While Superior Tonics are called “herbs,” they are, again, really the world’s most profound foods. By providing hundreds of anti-oxidants and other phyto-nutrients, they repair damage done to cells throughout the body, and strengthen all the organ systems and the blood. By strengthening the Spleen System, they help the mother digest and assimilate nutrients, so that she can more easily incorporate them in milk for her child. By strengthening Kidney “Essence” as no common foods or nutrients can, they help the new mother recover more quickly and completely from the birthing trauma than she ever could on her own. This, of course, helps make both mothers and children healthier, happier, and stronger.

Mother & Child also stands alone in providing 162 mg. of lactose free colostrum in each day’s use, to help confer dynamic, immune enhancing properties to the child, and an equal amount of L-Taurine, an amino acid that is extremely important to the development of the child’s central nervous system and vision.

Vital Factors for Brains and Bones

Mother & Child is also better for your child’s brain and bone development than other formulas.

For example, each IU of their vitamin E (d-alpha tocopherol) is balanced with a full milligram of gamma tocopherol, and with a full spectrum of tocotrienols. This is because gamma tocopherol protects brain cells just as alpha tocopherol protects the heart. Studies show that equal levels of alpha and gamma tocopherol produce greater brain development than alpha tocopherol alone. In today’s world, nothing is more important to a child’s future than the way in which his or her brain develops, and there is no better nutrient for this development than gamma tocopherol.

In addition, our natal products provide calcium and magnesium not in the standard, 10:4 ratio, but in roughly equal amounts, because, when calcium exceeds magnesium in the diet, both bone and cardiovascular health may suffer. Magnesium is the nutrient in which Americans are by far the most deficient. If mothers lack magnesium, their fetus or nursing child will, as well. If we don’t get at least 600 mg. of magnesium per day, we may be setting ourselves—and our children—up for countless health problems.

Superior Tonic Herbs for New & Expectant Mothers

Mother FOR OVER 4000 YEARS, the peoples of Asia have benefited from the most holistic, natural health systems on Earth. Superior Tonic Herbs are the foundation on which these systems are built.  In Traditional Chinese Medicine, every cell in the body belongs to one of five major organ systems (Heart, Lung, Spleen, Kidney, and Liver) or the blood. When energy flows freely between these systems, each system works efficiently, and health is abundant. When energy flow is disturbed, however, imbalances occur. If not corrected, these imbalances become impediments to efficient metabolism, and lead to disease.

Throughout the centuries in which Chinese Medicine has flourished, over 15,000 herbs have been used as medicines. Yet, in all that time, only 22 have been classified as true Superior Tonics, and about 30 more as tonic helpers.

To qualify as a Superior Tonic, an herb must strengthen, invigorate or restore normal function to at least one of the body’s major organ systems, build at least one of the three major types of energy, and be safe for regular, daily consumption. Superior Tonic Herbs are used daily by over one billion Asians as dietary supplements that generate energy, enhance immunity, promote mental clarity, maximize longevity, and so on.

Superior Tonic Herbs bestow such profound health benefits by providing hundreds of phyto-nutrients that exist in no other plants on Earth. Many of these nutrients are anti-oxidants that protect cells from free radical oxidation. Because the anti-oxidants in each herb are different, and protect cells in different organ systems, the right combination of Superior Tonic Herbs can help protect every cell in the body.

Expectant and nursing mothers channel huge amounts of energy to the developing fetus and newborn child. In Chinese terminology, this energy is called “jing,” or “essence,” and resides deep within the Kidney System. Because this is the energy that we pass on at birth, and that we need to see us through illness or injury, it is vital to keep this energy abundant both during and after pregnancy. Superior Tonic Herbs are the only known supplements in the world that directly rebuild this energy. For this reason, they should, along with nutrient dense green foods, form the foundation of every nutritional regimen.

Following is a brief description of how the foods and tonic herbs in our natal formulas help support optimal health.

Spirulina: Provides Nature’s most perfect protein. Rich in pre-made glycogen (to provide nearly instant energy). Loaded with phycocyanin (a profoundly important anti-oxidant) and naturally occurring vitamins.

Barley Grass Juice Powder: Rich in chlorophyll and SOD, (an anti-oxidant that is thought to slow the aging process). Great sources of vitamins and minerals.

Reishi mushroom: The true master tonic. Supports all five organ systems, the Blood, and all three energies. Is used in Asia for enormously wide range of medical treatments, but is not a medicine. It is used because it balances the body so that the body can then heal itself.

Lycii fruit: Tonic to Liver, Kidney, Lung Systems, and Blood. Among the most prized of all longevity tonics. Often used to help prevent morning sickness. Also a primary sexual tonic, meaning that it strengthens the reproductive process.

Codonopsis root: A ginseng replacement where the “heat” of ginseng is not desired. Tonic to Spleen and Lung Systems, and to the Blood. Rich in immune building factors.

Astragalus: Tonic to Spleen and Lungs. Highly treasured immune tonic. Supports digestion, eliminative functions.

Ophiopogon root: Tonic to Lung, Heart Systems, and stomach. Promotes mental and emotional clarity.

Gynostemma leaf: Tonic to Spleen, Lungs, Kidneys, Liver, and Heart Systems, and to all three major energy treasures. Regarded as a virtual “cure-all” in Japan.

Eucommia bark: Tonic to Kidney and Liver Systems. Highly prized for helping to rebuild the “Essence” that women lose so much of during pregnancy and childbirth.

Asparagus root: Tonic to Lung, Kidney, and Heart System, and important in rebuilding “Essence.” Highly prized as tonic to Kidney “Yin,” which is vital to the production of fluids that rebuild sexual interest and ability after childbirth.

Achyranthis herb: Directs energy of other herbs toward the reproductive tract, so that their energies reach the Kidney System and work toward rebuilding “Essence.”

Prepared Rehmannia root: Tonic to Kidney, Liver, and Heart Systems. Called “Kidney’s Own Food,” and considered strongly rejuvenative and life-lengthening. Used in nearly every reproductive tonic in China because it supports Kidney “Essence.”

White Peony: A marvelous Liver and Spleen Tonic. Cleanses, builds, and nourishes the Blood. Harmonizes the actions of other herbs.

Cornus fruit: Works with “Essence” and “Yin” tonics as astringent, meaning that it helps preserve the vital moisture essential to healthful feminine function.

Vegetarian diets for pregnancy and children

A healthy plant-based diet is the perfect solution for these vital stages of life.

Pregnant women

Vegan women are generally healthier than their carnivorous and dairy-consuming counterparts and are therefore already well on their way to trouble-free, easy pregnancies. A study of 1,700 pregnancies at The Farm, a large vegan community in Tennessee, showed that vegan mothers-to-be have a record of safety that would delight obstetricians. Only one in 100 women delivered their babies by Caesarean section, and in 20 years, there was only one case of pre-eclampsia (pregnancy-induced hypertension), which occurs in at least 10 per cent of all pregnancies in the UK. Other studies have found similar results.

Special needs during pregnancy

All pregnant women need to consume extra protein. There's plenty to be found in plant foods such as tofu, tempeh, beans, nut butters and mock meats like veggie burgers and soya sausage, and these foods don't come with the artery-clogging cholesterol and saturated fat found in animal products. For calcium, pregnant women should eat plenty of green leafy vegetables such as broccoli or kale. The calcium from most green vegetables is actually more absorbable than the calcium in cow's milk. Another reason to avoid cow's milk: The protein in it can cross the placenta and even enter a woman's breast milk, possibly sparking the production of antibodies that lead to insulin-dependent diabetes. Other plant foods rich in calcium include soya milk, almonds, figs, blackstrap molasses, sesame seeds, tahini and calcium-fortified fruit juices. Expectant mothers also should consume plenty of iron, folic acid and vitamins, including D and B12 - all of which a well-balanced vegan diet and routine prenatal vitamins will provide.

Vegetarian children

It's never too early to learn healthy eating habits.

According to a study in The New England Journal of Medicine, at least 60 per cent of children and young adults have early atherosclerotic damage. Wholesome plant-based foods make for strong, healthy bodies with a great head start in life. In the seventh edition of his world-famous Baby and Child Care, the highly respected late paediatrician Dr Benjamin Spock recommends that parents raise their children on a vegan diet. '

We now know that there are harmful effects of a meaty diet,' wrote Spock. 'Children who grow up getting their nutrition from plant foods rather than meats have a tremendous health advantage. They are less likely to develop weight problems, diabetes, high blood pressure and some forms of cancer ... I no longer recommend dairy products. ...There was a time when cow's milk was considered very desirable. But research, along with clinical experience, has forced doctors and nutritionists to rethink this recommendation.' Many children are subtly or violently allergic to milk proteins. Sniffles and intestinal distress dismissed as colds and colic can actually be signs of lactose intolerance.

Pediatricians often find that chronic ear infections and respiratory problems are aggravated when milk is part of a child's diet. Drinking milk has also been linked to asthma and intestinal bleeding and is suspected of triggering juvenile diabetes, a disease that causes blindness and other serious effects. Some children's bodies reject cow's milk protein as a foreign substance and produce high levels of antibodies to fend off this 'invader'. Unfortunately, these antibodies also destroy the cells that produce insulin in the pancreas, leading to diabetes. Children can get all the calcium they need from plant foods like broccoli, chickpeas, almonds, black beans, tahini, dried figs, collards, kale, tofu, fortified soya milk and orange juice - without the risk of developing serious health problems that could plague them for a lifetime.

Raising vegan kids

When my daughter, Jilly, was a baby, she never had colic, ear infections, flu or any serious illness. My infant son, Dash, is now following her example. My friends think I'm just lucky, but the truth is in what my kids eat. When you get rid of meat, dairy products and eggs, good health is almost sure to follow. My decision to raise vegan children scandalised my family.

"They'll be sickly and scrawny,' they warned. In fact, I've given my kids a better start in life than the majority of children. But I confess I had moments of doubt in the beginning. True, I'd been a vegetarian for years. But weren't children different? The list of adult illnesses stemming from a meat- and dairy-based diet reads like a Who's Who of modern-day killers - heart disease, cancer, high blood pressure, stroke. But what about babies? The answer shocked me. Drinking milk has been linked to asthma, allergies, intestinal bleeding and even juvenile diabetes! That clinched it! My paediatrician was sceptical at first. (When my daughter began eating solid food, my doctor had said, 'Mix the meat with fruit to disguise it. Babies don't like meat. It tastes dead to them.') However, the consulting nutritionist confirmed what I'd already learned: Kids not only don't need any animal products, they're much better off without them! She gave me confidence and some easy instructions. Here's what I found:

Breast-fed babies are happier and healthier than formula-fed infants. Most babies who suffer from the endless crying and the discomfort of colic are fed dairy-based formula. I passed along protection from illness in my breast milk, and since I'm vegan, I didn't pass along pesticides, which collect in animals' muscle and fatty tissue. I even lowered the chances of SIDS - Sudden Infant Death Syndrome - which is more likely to strike formula-fed infants.

If you don't breast-feed, soya-based formula is easier on babies' digestive systems. than cow's milk and is available from chemists in powder form.

My children have never had a problem with protein, calcium or iron. Most kids and adults eat too much protein, and because they get it from animal products, they get a whopping dose of artery-clogging fat with it. Too much protein actually causes the body to lose calcium, so drinking cow's milk is one of the least effective ways to strengthen bones.

Every day, my kids prove me right. My daughter is now 6 years old. She is tall and strong and athletic. She was playing soccer by 18 months and taking dance class at 3. She has never had bronchitis or strep throat. Her little brother is gaining weight at a rate that astounds his doctors. There are other benefits, too. My daughter is old enough now to understand that a hamburger was once a cow and that a drumstick came from a chicken. She feels good about doing her part to stop cruelty to animals.

Preventing serious birth defects

Spina bifida ("open spine") can cause lifelong disabilities, including loss of bowel control and lower-body paralysis. Babies with anencephaly, in which part or all of the brain is missing, die before or shortly after birth. By getting adequate folate or folic acid daily, before and during pregnancy, you can reduce your baby's risk for NTDs by 70 percent!

Recent research also has found that getting the recommended amount of folate cuts a baby's risk of being born with a cleft lip or cleft palate by one-third. But perhaps the most intriguing new science, involves folate and preterm-birth prevention. In a new unpublished study of 38,000 women sponsored by the National Institutes of Health, folate supplementation for at least one year before conception was linked to a 70 percent decrease in very early preterm deliveries—20 to 28 weeks—and a 50 percent decline in deliveries at 28 to 32 weeks. Additionally, new research has shown that folic acid taken early in pregnancy can reduce the risk of preeclampsia, a potentially life-threatening blood pressure disorder.

It's vital for other reasons as well. "Folic acid helps maintain and produce new cells," says Dawn Jackson Blatner, R.D., national media spokeswoman for the American Dietetic Association. Every cell of your growing baby's body requires it. You need it, too, Mom: producing enough red blood cells to prevent anemia—a common problem during pregnancy—is dependent on your getting enough folate.

Why Some Women Need More Folate

Though any woman can give birth to a baby with a neural-tube defect (NTD), a few factors increase risk: diabetes; certain medications; obesity; Hispanic ethnicity; and a previous NTD-affected pregnancy. According to researcher Jean Lawrence, women who have had such a pregnancy should take 4 milligrams of folic acid daily—10 times the amount recommended for non-pregnant women—before they conceive.

Top Pregnancy Nutrient:

Folate

Getting enough of this B vitamin is more crucial than ever in preventing birth defects and prematurity. Here's what you need to know to give your baby the best start.

By Nancy Gottesman

Start taking it NOW

For folate to confer the greatest benefits, you need to supplement before conceiving. Birth defects of the spine and brain occur in the first weeks of pregnancy; often, this is before a woman even realizes she's pregnant. Because 50 percent of pregnancies are unplanned, the current Institute of Medicine recommendation is that all women capable of becoming pregnant get 400 micrograms of folic acid from supplements or fortified foods in addition to their intake of folate from a varied diet.

If you are already expecting, getting the folate you need is still important. In fact, once pregnancy is confirmed, the IOM- recommended intake for supplementation jumps to 600 micrograms. Most prenatal vitamins contain 800-1,000 micrograms, which will cover your folic acid needs. But you also need to eat foods like fortified cereals, beans and leafy greens (see box at below). "Folate is better absorbed by your body from food," explains Blatner.

Best Foods For Folate

It's better to get folate from food. Here's how much of your daily value is in each serving.

•Fortified cereals (3/4 cup) 400 micrograms 100%

•Black-eyed peas (1/2 cup) 105 micrograms 25%

•Frozen spinach (1/2 cup) 100 micrograms 25%

•Asparagus 4 spears 85 micrograms 21%

•Enriched egg noodles (1/2 cup) 50 micrograms 13%

•Fortified wheat bread (2 slices) 50 micrograms 13%

•Peanuts (1 ounce) 40 micrograms 10%

•Orange juice (3/4 cup) 35 micrograms 9%

•Banana (1 banana) 20 micrograms 5%

Having a Healthy Pregnancy

Not all birth defects can be prevented, but a woman can take some actions that increase her chance of having a healthy baby.  Many birth defects happen very early in pregnancy, sometimes before a woman even knows she is pregnant.  Remember that about half of all pregnancies are unplanned. 

Overcoming Barriers: Relief from Common

Discomforts during Pregnancy

The following information discusses the common discomforts during pregnancy and methods of relief.

Nausea and Vomiting

Nausea and vomiting during the first trimester of pregnancy can be annoying, but it generally begins to subside by the beginning of the second trimester. Symptoms of morning sickness may actually occur at any time throughout the day, though vomiting tends to be more common between 6 A.M. and noon. Although the etiology of nausea and vomiting during pregnancy is unknown, it may be caused by hormonal factors such as a rise in estrogen or the placental hormone human chorionic gonadotropin (HCG). Stress or fatigue may exacerbate the condition. There is no cause for alarm unless the mother begins to lose weight or becomes severely dehydrated. If she cannot retain either foods or fluid for 6 hours or longer, a physician should be contacted.

If nausea or vomiting persists into the second trimester or severely interferes with the mother's life, it may be a more serious condition. Hyperemesis gravidarum

is severe and unrelenting vomiting and usually requires intravenous replacement of nutrients and fluids. If the mother receives total parenteral nutrition or nasogastric tube feedings for the treatment of hyperemesis gravidarum, appropriate levels of vitamins and minerals should be included, with careful monitoring and follow-up.

There are no specific foods to avoid, but many women find it is helpful to eat small, frequent, meals; drink liquids between rather than with meals; and avoid fried and greasy foods. Some women find it helpful to reduce coffee intake and to prepare meals near an open window to avoid cooking odors. If nausea upon getting out of bed in the morning is a problem, dry toast or crackers eaten before gettingout of bed may provide relief. Snacks to keep handy while working or traveling might include dried fruit, crackers, and small cans of juice.

Heartburn

In late pregnancy, when the fetus rapidly grows in size, the uterus pushes up against the stomach, which may cause a feeling of fullness in the mother. Additionally, because of the action of progesterone (which can cause relaxation of smooth muscles), a relaxation of the gastroesophageal sphincter may occur, resulting in some reflux of gastric contents into the lower esophagus. This is the cause of the heartburn so common during the final weeks of pregnancy. The best dietary remedies include eating small frequent meals, avoiding foods high in fat, drinking fluids between rather than with meals, limiting spicy foods, and avoiding lying down for 1 to 2 hours after eating. Many women find relief by wearing loose fitting clothing around the abdomen. Expectant mothers should not take antacids without approval of a primary care provider. Heartburn generally disappears after delivery of the infant.

Constipation

As mentioned earlier, constipation is common during the first and third trimestersbof pregnancy. During the first trimester, progesterone (which slows GI motility) may be responsible. In the third trimester, the growing fetus crowds the other internal organs, again possibly slowing GI motility. Although bothersome, constipation responds well to dietary treatment. A generous intake of fiber, such as whole grain cereals, fresh fruit, and raw vegetables, as well as inclusion of plenty of fluids should alleviate constipation. Moderate exercise such as a daily walk may also help. The recommendations for alleviating constipation also help prevent hemorrhoids. Over-the-counter laxatives or enemas should not be used unless prescribed by a physician.

NUTRITION DURING LACTATION

All sexually mature female mammals possess milk-producing mammary glands and are able to produce milk specifically formulated to provide optimum growth and development for their offspring. Although there are historical accounts of wet nurses and even artificial feeding implements dating back to Greek and Roman times, breastfeeding (lactation) was the primary mode of infant feeding until this century in the United States and around the world.

Since World War II, however, there has been a dramatic decline in the incidence and duration of breastfeeding worldwide. Currently close to 60% of mothers in the United States initiate breastfeeding at hospital discharge, but by 5 to 6 months after birth, only about 20% of American infants are breastfed.38'39 In many developed countries, such as Sweden, all women initiate breastfeeding and continue for most of the infant's first year of life. Although there is not one isolated cause for poor breastfeeding rates in the United States, it can be attributed to a multitude of causes. These include the advertising of breast-milk substitutes, lack of support for the breastfeeding mother, lack of knowledge of lactation by healthcare professionals, short postpartum hospital stays, and the rise in maternal employment without appropriate facilities to nurse infants or pump and store breast milk.

The American Dietetic Association and the American Academy of Pediatrics have policy statements advocating exclusive use of human milk as the preferred feeding choice for infants for at least the first 4 to 6 months of life.

Ideally, breastfeeding should occur for the entire first 12 months accompanied by appropriate weaning foods. Breastfeeding offers advantages for both infant and mother (Box 11-3).

Anatomy and Physiology of Lactation

The human breast begins its development in utero and goes through two further stages of change after birth: at puberty and during pregnancy. The mature human breast consists of a system of alveoli and ducts. Myoepithelial cells surround the milk-producing glands, located in the alveoli. The ductules emerge from the alveoli to carry the milk to the lactiferous ducts, which eventually empty into the lactiferous sinuses. The lactiferous sinuses are located behind the areola, or the darkened area of the nipple where the infant latches on during nursing.

Throughout the course of pregnancy, the breast tissue undergoes considerable development. Under the influence of progesterone, the lobules or alveoli increase in size and number, while estrogen stimulates proliferation of the ductal system.

Together, these changes render the breast completely capable of milk production after delivery. An uncommon occurrence is a failure of the breasts to undergo development during pregnancy. A women who does not notice any changes in her breasts during pregnancy, particularly if she is pregnant for the first time, should receive postnatal assistance to determine her ability to fully lactate. Most women are able to fully lactate with no problems. Actual size of breast has no bearing on ability to breastfeed.

Lactation is a normal process beginning when various hormones interact following delivery of the infant. Before the onset of labor, there is a rise in serum levels of oxytocin. This hormone is instrumental in initiating the uterine contractions of labor that bring about birth. Oxytocin and another hormone, prolactin, set off the lactation process.

Prolactin is primarily responsible for milk synthesis; oxytocin is involved with milk ejection from the breast.

As an infant is allowed to suckle after birth, a nerve impulse is sent to the mother's hypothalamus. This stimulates the anterior pituitary to secrete prolactin, which then stimulates milk production in the alveolar cells.

The infant sucking stimulus initiates the release of oxytocin from the posterior pituitary.

The flood of oxytocin into the breast tissue causes the myoepithelial cells around the glands to contract, thereby ejecting the milk into the infant's mouth. This is called the let-down reflex, or the milk-ejection reflex.

Many women report feeling a tingling sensation in their breasts when the let-down occurs. Additionally, if a mother hears her infant's cry or sees another infant, she may experience a let-down accompanied by a rush of milk ejecting from her breasts. Deterrents to the let-down reflex may include fatigue, stress, alcohol, smoking, and some prescription medications.

An important point to note is that milk production is a supply-and-demand mechanism. The more an infant is allowed to nurse, the more nerve stimulation there will be, resulting in a rise in prolactin levels followed by increased milk production.

Promoting Breastfeeding

To increase the incidence and duration of breastfeeding in the United States and around the world, healthcare professionals must take measures ensuring that appropriate breastfeeding policies are adopted and practiced in hospitals providing maternity care. In 1991 the World Health Organization and UNICEF launched the Baby Friendly Hospital Initiative. The initiative includes "Ten Steps to Successful Breastfeeding" that the hospital must be willing to take to become infant friendly.

Among the steps is breastfeeding education for all mothers, no separation of mother and infant following birth except for medical reasons, and no supplemental feedings unless medically indicated. Nurses play a key role in prenatal counseling and in postpartum support to help mothers successfully establish and maintain lactation. Obstetric nurses should consult a lactation specialist if an infant or mother has difficulties initiating breastfeeding.

Another influence on successful lactation is acceptability of lactation within the cultural and ethnic communities of which the mother is a part. Cultures in which breastfeeding is common include Chinese, Finnish, Indian, Saudi Arabian, Muslim, South African, and Swedish. In the following cultures, breastfeeding is common, but infants are not given colostrum because it is considered bad or unclean: Cambodian, Filipino, Haitian, Japanese, Korean, Laotian, Mexican, and Vietnamese.

Socioeconomic and education levels are influences that help or hinder a mother's attempt at successful lactation. Organizations such as La Leche League or community-based mothers' groups may provide invaluable support to nursing mothers, particularly those nursing for the first time.

In the final weeks of pregnancy, the alveoli swell with colostrum, a thick, yellowish substance that is high in protein but contains less fat and glucose than mature breast milk. Before childbirth, some women experience leakage of colostrum from the nipples. In contrast, mature breast milk does not leak during pregnancy and is not secreted until several days after childbirth.

*Cow’s milk should never be given to an infant. Its composition is not suitable and its proteins are difficult for the infant to digest.

Colostrum is secreted during the first 48–72 hours postpartum. Only a small volume of colostrum is produced—approximately 3 ounces in a 24-hour period—but it is sufficient for the newborn in the first few days of life. Colostrum is rich with immunoglobulins, which confer gastrointestinal, and also likely systemic, immunity as the newborn adjusts to a nonsterile environment.

After about the third postpartum day, the mother secretes transitional milk that represents an intermediate between mature milk and colostrum. This is followed by mature milk from approximately postpartum day 10. As you can see in the accompanying table, cow’s milk is not a substitute for breast milk. It contains less lactose, less fat, and more protein and minerals. Moreover, the proteins in cow’s milk are difficult for an infant’s immature digestive system to metabolize and absorb.

The first few weeks of breastfeeding may involve leakage, soreness, and periods of milk engorgement as the relationship between milk supply and infant demand becomes established. Once this period is complete, the mother will produce approximately 1.5 liters of milk per day for a single infant, and more if she has twins or triplets. As the infant goes through growth spurts, the milk supply constantly adjusts to accommodate changes in demand. A woman can continue to lactate for years, but once breastfeeding is stopped for approximately 1 week, any remaining milk will be reabsorbed; in most cases, no more will be produced, even if suckling or pumping is resumed.

Mature milk changes from the beginning to the end of a feeding. The early milk, called foremilk, is watery, translucent, and rich in lactose and protein. Its purpose is to quench the infant’s thirst. Hindmilk is delivered toward the end of a feeding. It is opaque, creamy, and rich in fat, and serves to satisfy the infant’s appetite.

During the first days of a newborn’s life, it is important for meconium to be cleared from the intestines and for bilirubin to be kept low in the circulation. Recall that bilirubin, a product of erythrocyte breakdown, is processed by the liver and secreted in bile. It enters the gastrointestinal tract and exits the body in the stool. Breast milk has laxative properties that help expel meconium from the intestines and clear bilirubin through the excretion of bile. A high concentration of bilirubin in the blood causes jaundice. Some degree of jaundice is normal in newborns, but a high level of bilirubin—which is neurotoxic—can cause brain damage. Newborns, who do not yet have a fully functional blood–brain barrier, are highly vulnerable to the bilirubin circulating in the blood. Indeed, hyperbilirubinemia, a high level of circulating bilirubin, is the most common condition requiring medical attention in newborns. Newborns with hyperbilirubinemia are treated with phototherapy because UV light helps to break down the bilirubin quickly.

Energy and Nutrient Needs during Lactation

A large proportion of the energy stores laid down as adipose tissue during pregnancy are mobilized in lactation. Both BMR and maternal activity return to their prepregnant levels. The energy cost of milk production is approximately 500 to 800 kcalories per day depending on the volume of milk production. The RDA recommends increases for protein (65 g/day for the first 6 months of lactation and 62 g/day for the second 6 months of lactation) and for most of the vitamins and minerals over the normal adult levels. The mother can meet most of these increases by consuming a well-balanced diet.

A woman need not avoid certain foods while breastfeeding unless a problem occurs.

For example, some infants are fussy following the mother's consumption of gas-producing vegetables such as cabbage, onions, and broccoli.

Adequate fluid intake is important during lactation. The average woman produces 750 to 1000 ml of milk per day. She can replace this fluid through consumption of water or juice. Coffee or cola drinks should be avoided or used on a minimal basis. They act as diuretics in the mother's body and caffeine, a stimulant, passes into breast milk in small amounts. The old myth stating that alcohol helps a mother relax and enhances milk production should not be followed. Alcohol not only passes into milk, becoming available to the infant, but also may inhibit oxytocin, consequently reducing the let-down reflex.

Despite the desire of most women to return to their prepregnancy weight quickly, rapid weight loss should not be encouraged while breastfeeding. Recent research shows that women achieve weight loss, without compromising their nutritional intake or the infants, when breastfeeding without the use of supple mentary formula continues for at least 6 months. The amount of fat loss is highly variable between women ).

Contraindications to Breastfeeding

Common colds, the flu, and even most illnesses requiring short-term antibiotic therapy do not require cessation of breastfeeding. A number of maternal illnesses or conditions are contraindications to breastfeeding (see note in margin).

Most medications for mild illnesses are safe for the mother to take while breastfeeding.

Mothers should always remind their healthcare providers they are nursing an infant should the need for a medication arise. The American Academy of Pediatrics has classified medications into five categories based on safety considerations.

For mild illnesses as well as for chronic diseases, a medication compatible with breastfeeding can usually be found and substituted for one that is contraindicated.

The amount of the maternal dose of drug actually secreted into the milk depends on the route of administration, the size of the molecule, ionization, the pH of the medication, solubility, and protein binding. Healthcare providers might keep this information in mind as they consider prescription medications for nursing mothers.

The Centers for Disease Control and Prevention recommend that all women in the United States infected with HIV not breastfeed their infants. In developing countries where the risk of death from diarrhea caused by inappropriate bottle feeding is far greater than the risk of transmission of HIV via human milk, the World Health Organization recommends that breastfeeding continue in these situations.

The woman with active acquired immunodeficiency syndrome (AIDS) and opportunistic infections is unlikely to have the physical strength to successfully lactate. Because of the advent of hepatitis В vaccinations given at birth, hepatitis В is no longer a contraindication to breastfeeding. However, there is mother-to-infant transmission of hepatitis C45 and therefore, mothers with hepatitis С should not breastfeed.

Energy and Nutrient Needs during Infancy

Dramatic changes in growth and development occur during the first 12 months of life. In the first year, a human infant is expected to triple its birth weight and increase its length by 50%. In addition, after birth, organs such as the kidney and brain continue to develop and mature. In no other period of life do growth and development occur so rapidly. To support this rapid growth and development, the appropriate balance of all nutrients is essential. At the same time, parents, caregivers, and healthcare professionals must realize that infants have specialized nutrient needs. Advice appropriate for adults, and even older children, is inappropriate for infants, particularly with regard to fat and fiber intake and weight gain patterns.

Energy

The World Health Organization suggests that infants receive 108 kcal/kg/day for the first 6 months of life and 98 kcal/kg/day from 6 months until the first birthday.

Adequate energy intake will be reflected in satisfactory gains in length and weight as plotted on a National Center for Health Statistics (NCHS) growth chart (see Appendix G). Infants should not have a restricted fat intake. Well-meaning parents should not place their infants on low-fat diets. Human milk, in fact, is high in cholesterol and fat content. Omega-3 fatty acids are plentiful in human milk, particularly if the mother includes fish in her diet on a regular basis. These fatty acids have been found to be essential for proper brain and nervous system development.

Protein

Protein needs of infants have been hard to determine because of the difficulty of performing nitrogen balance studies on this population. Requirements are estimated based on the intake and growth rates of normal, healthy breastfed infants.

Protein requirement is highest during the first 4 months of life when growth is the most rapid. It is suggested that infants receive 2.2 g/kg/day from birth to 6 months of age and 1.6 g/kg/day for the second half of the first year. An excess of protein in an infant's diet can be problematic. Protein has a significant influence on renal solute load. The infant kidney is immature and unable to handle the large renal solute loads of an adult. Therefore increasing a normal infant's protein intake above the recommended amount should be avoided.

Vitamins and Mineral Supplementation

The DRIs may be consulted for appropriate levels of vitamins and minerals for infants. Breast milk or commercial formula should provide infants with all the vitamins and minerals needed for proper growth and development (Table 11-4).

During the third trimester of pregnancy, the fetus stores iron in its liver to be used during the postnatal period. By 4 months of age, this supply of iron is usually depleted. The iron in breast milk, although lower in absolute amounts, is more bioavailable than iron from commercial formula. Many breastfed infants do not need to be supplemented with iron. However, their iron levels should be assessed periodically. Infants who consume commercial formula should use the iron-fortified variety to prevent iron deficiency anemia.

Humans are able to manufacture vitamin D through exposure to the sun; many young infants may not receive enough sun exposure for adequate synthesis. Breast milk contains vitamin D, but it may not be present in levels sufficient to prevent vitamin D-related rickets. There are several documented cases of vitamin D-related rickets, particularly among fully breastfed infants who receive little or no sunlight exposure. Therefore it is recommended that all breastfed infants receive a daily oral supplement of vitamin D, unless they receive substantial sunlight exposure. Vitamin D can be toxic, so the recommended dosage should not be exceeded. Because vitamin D is present in commercial infant formula, formula-fed infants need not receive a supplement. Use of milk alternatives such as rice beverage ("rice milk") and soy health food beverage have also resulted in rickets. These alternatives, which are low in protein, calcium, and vitamin D, are not nutrient dense in comparison with breast milk, formula, or cow's milk.54 Healthcare providers need to emphasize to caregivers that although the term "milk" is used in reference to these beverages, they are not nutritionally equal to milk produced by humans or by animals.

The water supply of most major cities in the United States contains fluoride as a preventive measure against tooth decay. The availability of fluoride may be particularly important for infants and young children whose teeth are developing. Routine fluoride supplementation is not recommended for infants less than 6 months of age. Older infants may need to receive fluoride if their local water supply is not fluoridated, but an assessment of total exposure to fluorid (via water, or juice prepared from local water source) should be made before systemic fluoride is prescribed.

For example, many rural families who rely on well water should have water supplies assessed for fluoride content. Excess fluoride can result in fluorosis, or mottling of tooth enamel; consequently the dosage should be followed precisely.

Newborns are vulnerable to vitamin К deficiency (and thus hemorrhaging) in part because they lack intestinal bacteria to synthesize the vitamin. As a preventive measure, U.S. hospitals routinely give infants 0.5 to 1.0 mg of vitamin К by injection or 1 to 2 mg orally, once shortly after birth.

Food for Infants

The ideal food for the first 4 to 6 months of life is exclusive use of breast milk. As mentioned previously, breast milk has the correct balance of all the essential nutrients as well as immunologic factors that protect the infant from acute and chronic disease. The breast should be offered at least 10 to 12 times per 24 hours in the first several weeks. As the infant develops a stronger suck, more milk will be extracted with each nursing session and the frequency of feeding may decline. Although there is no specified time the infant should stay on the breast, between 10 to 15 minutes per breast (offering both breasts per session) is a good recommendation. It is important to realize this is a general guideline because all infants have different nursing styles. It may in fact be more appropriate to watch the infant—not the clock— in an effort to allow the infant to dictate when satiety is reached. The Teaching Tool box offers some suggestions to facilitate successful breastfeeding.

If a mother chooses not to breastfeed or if she has a medical condition contraindicating breastfeeding, a variety of formulas made from either cow's milk or soy are available. In addition, a number of specialty formulas, such as protein hydrolysate formulas, are available for infants with medical problems. The parents should consult their primary healthcare provider or nutrition care specialist to identify the most appropriate formula for their infant.

Formulas are either ready-to-feed, where no mixing is required, or are a powder or liquid concentrate to be mixed with water. To reduce the chance of lead leaching into water, tap water should be run for 2 minutes after it has been standing in the pipes and only cold water should be used for formula preparation. The formula should be mixed exactly as stated on the package, unless otherwise directed by a primary healthcare provider. Adding insufficient water can result in a high renal solute load, placing strain on the immature infant kidneys; overdiluting will precipitate undernutrition.

For parents or caregivers who may be non-English speaking or have low literacy skills, pictorial mixing instructions may be useful. Alternatively, asking the caregiver to demonstrate appropriate formula mixing may be suitable. Formula should never be heated in a microwave oven because microwaves heat food unevenly. Contents of a bottle appearing to be cool on testing may actually have portions that could scald an infant. All unused formula at the end of a feeding should be discarded if not used within 2 hours because of contamination by saliva enzymes and bacteria. Homeprepared formulas made from evaporated milk, popular in some cultures, are likely to be low in iron, vitamin C, and other essential nutrients and should be avoided Before 1 year of age, cow's milk, regardless of fat content or form (evaporated, liquid, or dried), should not be fed to infants. The fat in cow's milk is less digestible than the fat in breast milk or formula and contains less iron and more sodium and protein. These higher levels of solutes may lead to dehydration caused by increased urine volume to reduce solute levels in the body. Deficiencies of other nutrients, such as vitamin C, essential fatty acids, zinc, and possibly other trace minerals, develop because cow's milk is a poor source of these nutrients.

Cow's milk may be introduced after 1 year of age when at least two thirds of energy needs are fulfilled by foods other than milk. The delay in cow's milk consumption reduces the risk of developing a milk allergy. Reduced fat and nonfat milk is not recommended until age.

Introduction of Solid Foods.

Solid foods may be added to the infant's diet between the ages of 4 and 6 months. Infants who are introduced to solid foods before this time may be prone to excessive kcaloric intake, food allergies, and GI upset. Many parents and even some healthcare professionals believe offering an infant cereal in the evening will promote sleeping through the night. This belief, however, is not supported by research.

There are two basic issues when considering the introduction of solid foods to the infant's diet:

(1) how to introduce them

(2) and (2) what to introduce.

How to Introduce Solid Foods.

Parents and other caregivers may be anxious to introduce foods other than breast milk or formula to their infant's diet. Health professionals can assure them that it's best for the infant to be developmentally ready for solid foods. The infant should be able to sit with some support; move the jaw, lips, and tongue independently; be able to roll the tongue to the back of the mouth to facilitate a food bolus entering the esophagus; and show interest in what the rest of the family is eating. For example, the infant may try to reach and grab an item off of a family member's plate at mealtime. Likewise, parents should become familiar with satiety cues so as not to overfeed the infant. To indicate fullness the infant may turn her head to the side, refuse to open her mouth, or grimace when the spoon comes close to her mouth. The caregiver should respect these cues. The infant should never be force-fed. If the infant is overtired or is not interested in food, she ought to be removed from the high chair and the foods offered again later. When an infant reaches the age of 9 to 12 months, he may enjoy self-feeding.

Although this may be a messy process, caregivers should encourage the development of these skills through food exploration.

Appropriate Solid Foods during the First Year of Life.

The second half of the first year of life should be thought of as a transitional period; breast milk or formula is still the primary food, and the solid foods are complementary.48 Solid foods should be introduced gradually and one at a time with a 4- to 5-day interval between new foods. This timing is crucial because if the infant has any type of allergic reaction such as GI upset, upper respiratory distress, or skin reactions (e.g., eczema, hives), the offending food may be easily identified. Families with a documented history of allergies should delay introduction of solid foods until the infant is about 6 months old. If solid foods are introduced too early, the large protein molecules of the offending food may cross the intestinal barrier and elicit an immunologic response in the infant. As the gut matures, it is less likely to allow large unhydrolysed proteins to cross the mucosa.

Solid foods offered to the infant need not be commercial. Home-prepared foods are a good, practical alternative. There should be strict attention to sanitary food preparation procedures. Although infants should not be offered excessive sweets, naturally sweet fruits such as peaches offer them a taste satisfaction. Although salt should not be added to an infant's food, complete elimination of sodium from foods in the diet is neither practical nor recommended.

A variety of textures, colors, and tastes is important for infants, whether they receive home prepared or commercial infant foods. General guidelines for infant feeding are listed in Table 11-5.

Beverages during the First Year of Life.

Fruit juice, particularly apple juice, is offered to many infants. Fruit juice can make an important contribution to the diet as a source of vitamin C, water, and possibly calcium. Its use, though, may need to be monitored. Excess fruit juice (greater than 12 fluid ounces per day) may lead to diarrhea from carbohydrate malabsorption, growth failure, or, in some children, obesity caused by excess calories. All fruit juice given to infants (and children) should be pasteurized.

Special Nutritional Needs

The nutrition requirements of children with congenital or acquired health problems deserve special attention. These infants often have increased nutrient requirements, increased losses, or malabsorption. Significant drug-nutrient interaction often takes place as well. Although it is beyond the scope of this chapter to describe all of the children's special needs one might encounter in practice, a few of the major disorders are outlined. In all of these cases, a registered dietitian should be a part of the medical team.

The Premature and Low Birth Weight Infant

An infant is considered premature if he or she is born before 37 weeks' gestation.

Low birth weight infants may be full term or premature but weigh 2500 grams or less at birth. As medical technology becomes increasingly sophisticated, infants are surviving at younger ages and lower weights.

However, their developmental outlook may still be tenuous. Nutrition support of these infants plays a crucial role in successful long-term outcome. The major issues of concern in the premature infant are low birth weight, immature lung development, poor immune function, immature GI and neurologic function, insufficient production of digestive enzymes, inadequate bone mineralization, and minimal energy and mineral reserves.

Because the coordinated suck-swallow reflex is not fully developed until an infant reaches 34 weeks' gestation, initial feeding of the premature infant may need to be via total parenteral nutrition, tube feeding, or gavage feeding. Many criteria influence the route of nutrient delivery, and thus each infant should receive an individualized nutrition assessment by a registered dietitian who specializes in highrisk pediatrics.

Premature infants have increased needs for protein, kcalories, calcium, phosphorus, sodium, iron, zinc, vitamin E, and fluids. The best feeding choice for a premature infant is mother's milk with the addition of "human milk fortifier," which adds additional minerals and protein needed by the premature infant. Although the infant may not suckle well or may tire easily at the breast, the nurse can play a key role in helping the mother pump and store her milk in the neonatal nursery.

The milk may then be given by gavage even when the mother is not present.

If the mother chooses not to breastfeed, a variety of specialized infant formulas are available to meet the special nutritional requirements of the infant.

Recent research suggests these formulas should be fortified with long chain fatty acids to mimic what would be delivered via the placenta. Long chain fatty acids are essential for proper retinal and neurologic development. Premature and low birth weight infants require continual nutrition follow-up after discharge for at least the first year of life because they are at risk for feeding problems, developmental delays, and growth retardation.