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CO N T I N U I N G P R O F E S S I O N A L D E V E L O P M E N T
4 Page 51 4 Page 52 4 Page 53
Eggs multiple Katy Joness practice Guidelines on
choice questionnaire profile on care of the how to write a
vulnerable practice profile

Value of eggs during

This article is supported by

pregnancy and early childhood

NS680 Ruxton C (2013) Value of eggs during pregnancy and early childhood.
Nursing Standard. 27, 24, 41-50. Date of submission: November 3 2012; date of acceptance: November 11 2012.

Aims and intended learning outcomes

Abstract
The aim of this article is to describe the
The maternal diet is believed to influence infant health, as does diet in early nutritional benefits of eggs for pregnant women
life following the introduction of solid foods. Eggs, commonly available and for infants who are being introduced to
and low in cost, contain nutrients that may be of benefit during pregnancy solid foods. Specific nutrients found in eggs
as well as during weaning. Key nutrients include vitamin D, folate, iodine, are discussed and put into context alongside
selenium and long-chain n-3 polyunsaturated fatty acids (omega-3 fatty recommended intakes, and the role of these
acids). Data from a recent nutritional analysis of eggs are presented and nutrients in maternal and infant health. After
put in context with dietary reference values for the UK. The safety aspects reading this article and completing the time out
of eggs, including food safety and allergy, are also discussed. activities you should be able to:
Summarise
 the nutritional content of
Author eggs, and understand how and why their
Carrie Ruxton composition has changed over the years.
Freelance dietitian, Cupar, Fife, Scotland. Describe
 the health advantages of
Correspondence to: carrie@nutrition-communications.com including eggs in the diet of pregnant
women and infants.
Keywords Advise
 on food safety and allergy issues.

Allergy, diet and nutrition, eggs, food safety, infants, omega-3 fatty
acids, pregnancy, vitamin D, weaning Introduction
Pregnancy and weaning are life stages at which
Review a healthy, balanced diet is important, not only
All articles are subject to external double-blind peer review and checked for promoting growth and development, but
for plagiarism using automated software. also for minimising potential harm, for example
exposure to dietary toxins or teratogenic
Online substances. The physical changes that occur
during pregnancy make demands on the
Guidelines on writing for publication are available at nutritional status of the mother, although many
www.nursing-standard.co.uk. For related articles visit the archive of these are met by maternal adaptations, such
and search using the keywords above. as increased nutrient absorption or reduced
excretion (Derbyshire 2011a). The energy cost
of pregnancy amounts to only 200kcal per day,
a level easily met by increased energy intake
or reduced physical activity (Department of
Health (DH) 1991). During pregnancy, there is
an increased requirement for nutrients including
protein, vitamin A, vitamin C, thiamin
(vitamin B1), riboflavin (vitamin B2), folate

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 Learning zone nutrition

and vitamin D. Details of these requirements omega-3 fatty acids and arachidonic acid in
are listed in Table 1. There is also emerging infants have been associated with poorer visual
evidence that adequate intakes of long-chain and cognitive outcomes compared to infants
n-3 polyunsaturated fatty acids, referred to as who received supplements (Huffman et al 2011).
omega-3 fatty acids in this article, are important In addition, a review of the cognitive effect of
during pregnancy to safeguard cognitive, iron-deficiency anaemia in infants found
retinal and immune development in the infant evidence of altered social-emotional behaviour
(Eilander et al 2007, Calder et al 2010). and reduced social engagement (Lozoff 2011).
The maternal diet can influence infant Diet is, therefore, an important consideration
health, for example high intakes of caffeine are for women during pregnancy and infants
associated with low birth weight (Derbyshire following the introduction of solid foods. As
1 Explain why a 2011b), while a lack of folate in early pregnancy a commonly eaten food in the UK, eggs may
womans diet during increases the risk of neural tube defects (Garza have a role in helping these groups to achieve
pregnancy could affect and Rasmussen 2000). Rees et al (2005) found optimal intakes of vitamins and minerals. This
the health of her infant. that iron and folate intakes failed to meet article will consider the results from a recent
recommendations in east London mothers who nutritional analysis (DH 2012), and explore the
2 Describe three delivered low birth weight infants, defined as value of eggs in the diets of pregnant women
changes to the infants with a birth weight lower than 2,500g and post-weaned infants. Concerns about food
nutritional composition regardless of gestational age. In addition, it safety and allergy are also discussed.
of eggs between the is believed that maternal obesity can increase Complete time out activity 1
1980s and 2011, and a childs risk of becoming obese later in life
give one reason for (Koletzko et al 2012).
In infants, there is evidence that inadequate Nutritional value of eggs
each of these changes.
intakes of key nutrients in early life can inhibit Compositional data were published in 2012
3 Choose two optimal development or increase risk of disease following an analytical survey of 3,000 eggs
nutrients found in (Barker et al 2002). In one longitudinal study in the UK (DH 2012). The results are shown in
eggs and explain what of 12,000 infants, those receiving regular Table 2 and are compared with previous analysis
effect they may have vitamin D supplementation had a 78% from the 1980s (Holland et al 1989). Notable
on maintaining health. reduced risk of developing type 1 diabetes differences were found in eggs analysed in 2011.
at 14 years compared to those not receiving These included lower energy, fat, saturated fat
4 Use your knowledge supplementation (Hyppnen et al 2001). and cholesterol contents, and higher vitamin D
of the nutritional A review of infant feeding practices that may and selenium contents, than in eggs analysed
content of eggs to predispose children to type 1 diabetes identified in the 1980s. For the first time, measurements
explain to a pregnant difficulties with early weaning, late introduction of vitamin K, choline, omega-3 fatty acids and
woman why it may be of cereal foods and early use of cows milk (Knip the carotenoids lutein, zeaxanthin and lycopene
beneficial to include et al 2010). Low vitamin D status in early life were made. The differences between the 1980s
eggs in her diet. was also linked to increased risk of infection and 2011 analyses reflect a combination of
(Walker and Modlin 2009). Lower levels of changes to hen feeding practices, with a shift
from meat and bone meal to feeds based on
TABLE 1 sunflower, wheat and soya; use of feed enzymes
to improve nutrient absorption; changes in
Dietary reference values for energy and vitamins during pregnancy average egg sizes, with a smaller yolk and more
Females 19-50 years During pregnancy white in 2011; and an increase in average shell
Energy (kcal) 1,940 2,140
weight, from 11% in 1989 (Holland et al 1989)
to 12.5% in 2011 (DH 2012). Improvements
Protein (g) 45 51 to analytical methods may also have influenced
Vitamin A (mcg) 600 700 some of the nutrient values.
Vitamin B1 (mg) 0.8 0.9 Complete time out activity 2

Vitamin B2 (mg) 1.1 1.4 Several health implications arise from the
Vitamin C (mg) 40 50 analysis, such as the lower energy content per
Folate (mcg) 200* 400
edible portion (151kcal per 100g in 1989 versus
131kcal per 100g in 2011), which equates to a
Vitamin D (mcg) 5** 10 reduction from 78kcal to 66kcal for a standard
(Department of Health 1991, except for * NHS Choices 2011, ** EU recommended daily medium-size egg (58g including shell). The
allowance, European Commission 2008) (No UK vitamin D recommendation exists for fatty acid profile of eggs has also improved,
those aged five to 65 unless pregnant or breastfeeding)
with less saturated fat and more omega-3 fatty

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 acids, which is closer to recommendations TABLE 2
for healthy eating (DH 1991). The lower
Nutritional composition of eggs analysed in the 1980s and 2011
cholesterol content is of interest, although heart
health advice does not advocate restriction 1980s 2011 Direction
of cholesterol-containing foods such as eggs, Per raw Per raw of change
prawns and liver for most individuals (Gray large-size large-size
and Griffin 2009). egg (68g*) egg (68g**)
The improved vitamin D content up by Energy (kcal) 91 78
70% to 1.6mcg in a medium-size egg (58g
Protein (g) 7.6 7.5
including shell) and to 1.9mcg in an average
large-size egg (68g including shell) is Total fat (g) 6.8 5.4
important given concerns about vitamin D Saturated fatty acids (g) 1.9 1.5
status in the UK. The new data on choline,
vitamin K and omega-3 fatty acids provide Cholesterol (mg) 237 209
opportunities to consider how eggs may Eicosapentaenoic acid/ Not analysed 80
contribute to intakes of these nutrients. docosahexaenoic acid (mg)
According to EU regulations, foods that Vitamin A (mcg) 115 75
contain at least 15% of the recommended
daily allowance (RDA) per 100g for certain Vitamin D (mcg) 1.1 1.9
nutrients qualify for health maintenance claims Vitamin E (mg) 0.67 0.77
(European Commission 2008). By applying
these RDAs to the new data on eggs, it can Vitamin K 1 (mcg) 0.2 <6
be seen that eggs meet the criteria for several Vitamin K 2 (mcg) Not analysed 4.2
health claims (Table 3).
Thiamin (mg) 0.05 0.05
Complete time out activities 3 and 4
Riboflavin (mg) 0.28 0.30

Egg nutrients during pregnancy

Niacin (mg) 0.06 0.03
Specific nutrients found in eggs may help to Vitamin B12 (mcg) 1.5 1.6
support maternal health and fetal development Vitamin B 6 (mg) 0.07 0.08
during pregnancy. Figure 1 summarises the
contribution of one portion of eggs for an adult
Folate (mcg) 30 28
to reference nutrient intakes (RNI) the level that Choline (mg) Not analysed 170
is likely to meet the requirements of 97.5% of the
Calcium (mg) 34 27
population during pregnancy (DH 1991).
Phosphorus (mg) 121 107
Vitamin D Magnesium (mg) 7 8
There are growing concerns about vitamin D
insufficiency in the UK. The most recent Potassium (mg) 79 86
National Diet and Nutrition Survey (NDNS) Sodium (mg) 85 92
reported that 20% of teenage girls and 19%
of women were vitamin D deficient defined
Chloride (mg) 97 107
as a serum 25-hydroxyvitamin D level of less Iron (mg) 1.1 1.0
than 25nmol/L (Food Standards Agency and
Copper (mg) 0.05 0.03
DH 2012).
In studies of pregnant women in the UK, Zinc (mg) 0.8 0.7
rates of vitamin D deficiency vary, as do the Iodine (mcg) 32 30
cut-off points chosen for an adequate level
of serum 25-hydroxyvitamin D. In a survey Selenium (mcg) 7 14
of 99 pregnant women in Northern Ireland, Lutein (mcg) Not analysed 56
35% of women were vitamin D deficient
(serum 25-hydroxyvitamin D level of less
Zeaxanthin (mcg) Not analysed 4.2
than 25nmol/L) at 12 weeks gestation, Lycopene (mcg) Not analysed <1
which increased to 44% of pregnant women
at 20 weeks gestation, before declining (Adapted from Department of Health 2012); * calculated from edible portion of 60.5g;
to 16% of pregnant women at 35 weeks ** calculated from edible portion of 59.6g (as egg shell weights have increased)
gestation (Holmes et al 2009).

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A survey of 198 mothers from the and infectious disease in infants (Brannon
Southampton Womens Survey found 2012). In the Southampton Womens Survey,
vitamin D deficiency in 18% of women a low maternal vitamin D status was associated
(serum 25-hydroxyvitamin D level of less than with greater fat mass in offspring at four and
11nmol/L), and vitamin D insufficiency in five years and reduced bone-mineral content in
31% of women during late pregnancy (serum offspring at nine years (Javaid et al 2006).
25-hydroxyvitamin D level of 11-20nmol/L) For vitamin D, there are RNI for children
(Javaid et al 2006). A larger cohort (n = 977) up to three years of age, pregnant and lactating
from the same survey reported vitamin D women, and people aged 65 and older (DH
insufficiency in 35% of women at 35 weeks 1991). However, there is a European RDA for
gestation (serum 25-hydroxyvitamin D level vitamin D of 5mcg (European Commission
of less than 50nmol/L) (Crozier et al 2012). 2008) that provides a useful comparison, and a
Low vitamin D status during pregnancy daily recommendation of 15mcg in the United
has been associated with an increased risk of States (US) (Institute of Medicine 2010). In
pre-eclampsia and gestational diabetes in the the NDNS, the mean daily intake of vitamin
mother and a higher prevalence of wheezing D in women was 2.9mcg, down from 3.3mcg
in 2000 to 2001 (Food Standards Agency and
TABLE 3 DH 2012). The Chief Medical Officers of the
Nutrition and health claims for which eggs qualify UK (2012) restated advice that pregnant and
lactating women should be offered a daily
Percentage Nutrition Summary of health claims
RDA per claims*
vitamin D supplement of 10mcg. Exposure to
100g edible sunlight provides more than 90% of serum
portion 25-hydroxyvitamin D but, as vitamin D
synthesis only takes place during the summer,
Vitamin A 15.8 Source of Vitamin A contributes to skin
good dietary intakes are important for
health, vision and immune
function. maintaining vitamin D status all year (Ruxton
and Derbyshire 2009).
Vitamin D 63.0 Rich in Vitamin D contributes to Few foods are naturally rich in vitamin D,
absorption and use of calcium
therefore eggs are an important source,
and phosphorus, in bones,
teeth and muscle, and immune
especially as vitamin D3 (cholecalciferol)
function. in eggs is more bioavailable than vitamin D2
(ergocalciferol) used in certain fortified foods
Riboflavin 35.7 Rich in Riboflavin contributes to skin
and supplements (Trang et al 1998). Two
health, vision, red blood cells,
medium-size eggs (as defined in Figure 1)
nervous system, and reduction
of tiredness and fatigue. provide 32% of the pregnancy-specific RNI for
Riboflavin is an antioxidant. vitamin D, or 64% of the European RDA,
which is suitable for the general population.
Vitamin B12 108.0 Rich in Vitamin B12 contributes to
immune function, nervous
Folate
system, psychological function
and reduction in fatigue.
Folate is vital during pregnancy for normal
development of the neural tube, with low intakes
Folate 23.5 Source of Folate contributes to maternal increasing the risk of birth defects (Derbyshire
tissue growth during pregnancy,
2011c). A survey of 292 pregnant women found
cell division, psychological
function, and immune function.
poor compliance with the DHs recommendation
to take 400mcg folic acid daily in early
Phosphorus 25.6 Source of Phosphorus contributes to bones, pregnancy (Barbour et al 2012). Participants
teeth and cell membranes.
also reported barriers to the use of folic acid
Iodine 33.3 Rich in Iodine contributes to cognitive supplements, including poor memory, morning
function, thyroid hormone sickness and busy lives. A prospective study
production and thyroid function. of 12,445 non-pregnant women aged 20-34
Selenium 41.8 Rich in Selenium contributes to recruited to the Southampton Womens Survey,
spermatogenesis, hair, nails, reported compliance with pre-conceptual folic
and immune function. acid in only 2.9% of those becoming pregnant
Selenium is an antioxidant. (Inskip et al 2009). Two medium-size eggs
(Adapted from European Commission 2012); RDA = recommended daily allowance; provide 52mcg of folate, which represents 13%
*containing at least 15% of RDA enables a source of claim, while containing at least of the pregnancy-specific RNI, or 26% of the
30% RDA enables a rich in claim. RNI for the general adult population.

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 Iodine
In the UK, iodine intake has fallen below the
lower RNI (LRNI) in 20% of females aged
11-18 and 9% of women (Food Standards
Agency and DH 2012). As the LRNI is only
expected to meet the needs of 2.5% of the
population, intakes below this indicate an
increased risk of deficiency. A poor iodine
status has been found in up to 40% of pregnant
women in some UK studies (Kibirige et al
2004), and may be associated with low birth
weight and delays in infant neurological
and behavioural development (Ruxton and
Derbyshire 2010). Two medium-size eggs
provide 51mcg of iodine, which represents 36%
of the RNI for the general adult population;
there is no pregnancy-specific RNI for iodine.
Selenium
The role of selenium in pregnancy relates
to its effect on fertility, tissue growth and
lowering oxidative stress, which refers to cell
damage caused by oxidation (Derbyshire
2011d). Observational studies have suggested
that selenium deficiency may increase the
risk of several reproductive and obstetric
complications, such as infertility, miscarriage,
pre-eclampsia, fetal growth restriction,
pre-term labour and gestational diabetes. In
a survey of 126 pregnant adolescents, low
maternal selenium status was associated with
an increased risk of infants being born small for
gestational age, possibly because of a lowering
of placental antioxidant defences that can limit
fetal growth (Mistry et al 2012). A prospective
survey of 1,129 women in the Netherlands
followed from 12 weeks gestation reported that
women in the lowest quartile of serum selenium
had twice the risk of pre-term birth as women in
the upper three quartiles (Rayman et al 2011).
The NDNS reported widespread low
selenium intakes, finding that 52% of women
and 45% of teenage girls had intakes below
the LRNI (Food Standards Agency and DH
2012). The implications of this are unclear
because data on selenium status suggest that
current intakes are consistent with normal
biochemical results (Scientific Advisory
Committee on Nutrition (SACN) 2011a).
Two medium-size eggs provide 44% of the
adult female RNI for selenium, up from 21%
in the 1980s analysis; there is no pregnancy-
specific RNI for selenium.
Choline
Choline is a vitamin-like compound that
is used in the body to create phospholipids,
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FIGURE 1
Contribution of one portion of eggs to reference nutrient intakes in adults
60
50
Percentage recommendation
40
30
20
10
0
ac a-3
te
um
e
in
in
la
in
s
t t eg
ol
d
ni
id
Fo
Io
Ch
le
fa Om
ta
Se
Vi
y
(Contribution of two medium-size eggs (weight per egg 58g of which 50.6g is edible
weight) to reference nutrient intake of selected vitamins and minerals for the female adult
population; pregnancy-specific where available (Department of Health 2012))
a component of cell walls, and to produce the
neurotransmitter acetylcholine (Westermarck
and Antila 2000). The health benefits of
choline are not understood fully, although
an adequate intake appears to be important
during reproduction (Zeisel 2009). Choline
donates methyl groups to fetal deoxyribonucleic
acid (DNA), causing hypermethylation,
which is thought to inhibit genes that may be
detrimental to health. Animal studies, during
which pregnant rats were depleted in choline,
reported adverse effects on the fetal rat brain
(Zeisel 2011). A human supplementation trial
in 26 pregnant women investigated the effect
of 930mg versus 480mg of dietary choline per
day on levels of cortisol in cord blood and the
expression of genes responsible for regulating
cortisol. A higher maternal choline intake was
linked to lower levels of cortisol in cord blood a
more beneficial environment for the fetus and a
more optimal gene expression (Jiang et al 2012).
Choline may also be important in helping to
prevent neural tube defects. In a survey of
180,000 pregnant women in the US (Shaw et al
2009), those who had infants with neural tube
defects had significantly lower serum levels of
choline compared with women who had healthy
infants. The risk of a neural tube defect in
pregnancy was 2.4 times greater when
mid-pregnancy serum choline was low.
Eggs are one of the few natural sources of
choline in the diet, with two medium-sized eggs
providing 288mg of choline. There are no RNI
08/02/2013 12:22
 Learning zone nutrition

or RDA for choline, but a daily requirement of
550mg has been suggested (Zeisel et al 2003).
Omega-3 fatty acids
The role of omega-3 fatty acids during pregnancy
is still unclear, although it is known that the
specific omega-3 fatty acids, docosahexaenoic
acid and eicosapentaenoic acid, have a role in
many tissues, including the brain, retina, sperm
and red blood cells (Arterburn et al 2006).
Supplementation trials with fish oils during
pregnancy have reported benefits for infants,
such as better cognitive function (Helland et al
2003) and a lower risk of atopy (Calder et al
2010), although the evidence is inconsistent.
Intake of omega-3 fatty acids in the UK
falls below the recommendation of 450mg
per day (SACN and Committee on Toxicity
2004), probably because of low intakes of
oily fish (Ruxton 2011). Eggs contain 130mg
of omega-3 fatty acids per 100g, so two
medium-size eggs provide 140mg or 31% of
the daily recommendation. EU health claims
for omega-3 fatty acids are allowed for vision,
heart health and brain health when food levels
exceed 80mg per 100g (European Commission
2012). Eggs meet these criteria.
Weight management
Maternal obesity is rising, putting mothers
and young infants at increased risk of obstetric
FIGURE 2
Contribution of one medium-size egg to the reference nutrient intakes
in infants
complications (Derbyshire 2011e). A survey of
36,821 women in the UK found that obesity
in early pregnancy increased from 9.9% to
16.0% between 1990 and 2004, with an
increased prevalence in lower income mothers
(Heslehurst et al 2007). Concerns about
obesity have led to studies of healthy eating
plans or exercise interventions in pregnant
women. A meta-analysis of 44 of these trials,
involving 7,278 women, concluded that weight
management during pregnancy was safe and
could reduce weight gain by 1.42kg on average
(Thangaratinam et al 2012).
Weight management during pregnancy may
involve cutting down on high-fat, energy-dense
foods and switching to lower fat, high-protein
foods such as eggs. Six randomised controlled
trials investigated the role of eggs in weight
management (Ruxton 2012). The results
show a consistent beneficial effect of
egg consumption on reported satiety and
short-term energy intake, as well as
concomitant changes in the gut hormones
responsible for hunger control (Ratliff et
al 2010). One eight-week study reported
a significantly greater weight loss when
participants consumed egg-based breakfasts
versus cereal-based breakfasts (Vander Wal
et al 2008). The mechanisms probably relate
to the protein content of eggs or the specific
amino acid profile. Because eggs are naturally
portion-controlled, at 66kcal per edible portion
(50.6g) of a standard 58g medium-size egg,
they may also assist in dietary compliance.
Complete time out activity 5

100
Egg nutrients during early childhood
The early years of life from birth to five years
Percentage recommendation

80
are a critical period for growth and development
(SACN 2011b). The rich micronutrient content
60
of eggs may be beneficial in the diet once solid
foods have been introduced at six months of
40 age. A summary of the contribution of one
medium-size egg to nutrient recommendations
for infants is shown in Figure 2.
20

Vitamin A
0 In childhood, vitamin A a group of substances
including retinol and the carotenoids has a
A

us

on

um

ne

ac a-3
te
B
1

B
2

6
B

si u
in
la
in

or

di
Ir
in

in

in

s
ni

t t eg
12

m
Fo
m

id
Io
B
m

ph
m

ne

le

major role in the normal development of vision.

fa Om
ta
ta

ta

in
ta

ta

Se
os

ag
Vi
Vi

m
Vi

Vi

Vi

y
Ph

M
ta

Retinol helps the retina adapt to changes in light

Vi

(Contribution* (capped at 100% actual values for vitamin B12 and selenium were and colour, helping to prevent night blindness
350% and 120% respectively) of one medium-size egg (58g, of which 50.6g is edible (Bender 2002). Retinoic acid, another form of
weight) to reference nutrient intakes of selected vitamins and minerals (Department vitamin A, is an important factor in the control
of Health 1991) at age 7-12 months (mean reference nutrient intakes were calculated
for ages 7-9 months and 10-12 months where differences occurred)
of cell differentiation and turnover, which are
both features of normal growth (Bender 2002).

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 EU health claims for vitamin A include the
support of normal skin health, vision and
immune function (European Commission 2012).
The NDNS reported inadequate intakes
of vitamin A, below LRNI, in 9% of children
aged 18 months to three years and 4% of
children aged four to ten years (Food Standards
Agency and DH 2012). No data are available for
infants younger than this, although a national
survey of infants is under way (Medical Research
Council 2012). One medium-size egg (as defined
in Figure 2) provides 18% of the RNI for children
aged seven to 12 months or 16% of the RNI for
children aged one to three years (DH 1991).
Vitamin D
Bone mass accrues during childhood, reaching
a peak in the mid to late twenties (Smith 2000).
Vitamin D has a key role in bone accretion
by enabling calcium absorption in the gut
and maintaining the correct ratio of calcium
and phosphorus in the blood (Holick 1996).
Vitamin D deficiency in childhood is associated
with rickets, which seems to be re-emerging in
the UK, mainly in black and minority ethnic
groups (SACN 2003). EU health claims for
vitamin D include the support of immune
function (European Commission 2012), and
there is evidence that vitamin D status during
infanthood may influence the risk of infection
during childhood (Walker and Modlin
2009) and development of type 1 diabetes in
childhood or early adulthood (Knip et al 2010).
There are no data on vitamin D intake or
status in children younger than 18 months
in the UK. Poor vitamin D status was reported
in 20-34% of Asian children aged 18 months
to two years in one study (Lawson and Thomas
1999). The NDNS reported an average daily
intake of 1.9mcg in children aged 18 months
to three years, which is lower than previous
surveys (Food Standards Agency and DH
2012). The RNI for children aged seven months
to three years is 7mcg (DH 1991).
In addition, all children up to the age of five
years, unless consuming more than 500mL of
formula milk per day, should be given a daily
vitamin D supplement of 10mcg (Chief Medical
Officers of the UK 2012).
While breast-fed infants receive vitamin D
from their mothers milk, the levels may not
be adequate as a result of maternal vitamin D
deficiency (Emmett and Rogers 1997). One
medium-size egg provides 23% of the RNI
for children aged seven months to three years.
There is no RNI for children older than this
but, when compared with the European
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p41-50w24.indd 47
RDA of 5mcg, a medium-size egg would
provide 32%.
Phosphorus
Around 85% of phosphorus in the body can be
found in the skeleton, where it has a role
in supporting bone mineral content and
skeletal growth (Smith 2000). The remainder
is present in soft tissue, where it is a major
constituent of cell membranes and the
components of energy metabolism (DH
1991). Phosphorus deficiency may lead to
osteomalacia (softening of bones), growth
failure and defects in immune function (Smith
2000), but the condition is rare in the UK. The
NDNS provides no information on phosphorus
intake, but a previous survey in low-income
populations reported that children aged two to
ten years had satisfactory phosphorus intakes,
with only 1% of young females falling below
the LRNI (Nelson et al 2007). One medium-
size egg provides 23% of RNI for infants aged
seven to 12 months or 34% of RNI for infants
aged one to three years.
Omega-3 fatty acids
Omega-3 fatty acids have an important role in
normal brain and retina development, although
the benefits of supplementation are still being
evaluated (Arterburn et al 2006). Some clinical
trials indicate benefit for infants in terms of
immune function, visual acuity and cognitive
function (Huffman et al 2011), while other
studies show no significant effect. However,
there is evidence that omega-3 fatty acid intake in
young children is likely to be low (Koletzko et al
2012), and that a low omega-3 fatty acid status is
undesirable (Huffman et al 2011).
A secondary analysis of the NDNS found
that the mean daily intake of omega-3 fatty
acids in children aged four to ten years was only
113mg, probably driven by low average intakes
of oily fish, at just 21g per week (Ruxton 2011).
In addition, only 11-14% of young children
are regular oily fish consumers, making other
sources of omega-3 fatty acids, such as eggs,
red meat and poultry, of greater value.
At present, there are no specific
recommendations for omega-3 fatty acids
in children, only general advice to eat two
portions of fish per week, including a portion
of oily fish, which equates to 450mg omega-3
fatty acids per day (SACN and Committee on 5 Write a paragraph
Toxicity 2004). Therefore, one medium-size to explain the issue of
egg provides 70mg of omega-3 fatty acids, vitamin D insufficiency
which would provide 16% of this general in the UK to a colleague.
recommendation.
08/02/2013 12:22
 Learning zone nutrition
Eggs and food safety
Pregnant women, infants and young children
may be particularly vulnerable to food-borne
disease. Therefore, while eggs have always been
permitted in the diets of vulnerable groups, it
is typically advised that runny yolks should be
avoided because of the small risk that salmonella
may be present (NHS Choices 2011).
Since the 1990s, the safety of UK eggs has
improved considerably as a result of the Lion
Quality Code of Practice, which enforces
inoculation of hen flocks against salmonella
and involves other quality control measures.
Therefore, UK-produced eggs are now among
the safest in Europe (European Food Safety
Authority 2006). Two official surveys of
UK eggs found no evidence of salmonella
contamination inside any retail egg, and no
salmonella contamination in catering eggs
complying with Lion Quality Code of Practice
(Food Standards Agency 2004).
It is noteworthy that most eggs sold at retail
level comply with the code, whereas many
eggs used by caterers do not. This suggests that
vulnerable groups can consume retail eggs
with confidence, but should be prepared to
question the source of eggs offered in catering
establishments. A survey of 1,744 boxes of
imported eggs found salmonella on the shells
of 157 samples, with one in 30 boxes of six
eggs showing some contamination (Little et al
2006). In 2011, Spanish eggs used in English
food businesses were blamed for 136 cases
of food-borne disease (Health Protection
Agency 2011).
Allergy
Diagnosed food allergy affects 1-2% of adults
and 5-8% of children (Thomas 2001), with egg
allergy affecting 0.5-2.5% of young children
according to a meta-analysis of self-reported
or parental reported prevalence (Rona et al
2007). The potential allergens in eggs are the
6 How would you
three proteins found in the egg white. However,
tailor advice to
these proteins are partially destroyed by
the mother of a
cooking, meaning that some people can be
six-month-old infant
allergic to raw eggs, but not to cooked eggs.
to ensure she minimises
Where allergy to eggs occurs, it is most often
any risks when including
reported in childhood, leading to anaphylaxis in
eggs in her childs diet?
a minority of cases. However, most children with
an egg allergy will outgrow it before they go to
7 When you have
school (DH 2012). A survey of 40,104 families
completed the article,
in the US involving 2,020 cases of food allergy
you might like to write
reported that 28% of children with an allergy
a practice profile.
had developed tolerance to the food by the age
Guidelines to help you
of ten years (Gupta et al 2012). Children most
are on page 53.
commonly developed tolerance to eggs followed
48 february 13 :: vol 27 no 24 :: 2013 NURSING STANDARD / RCN PUBLISHING
p41-50w24.indd 48
by milk, with a smaller proportion outgrowing
allergies to tree nuts or shellfish (Gupta et al
2012). Even children with an egg allergy can
often tolerate cooked eggs in composite dishes,
for example in cakes (Saltzman et al 2012).
To reduce allergy risk, it is recommended that
infants are not offered eggs until they reach six
months, the age at which the introduction of
solid foods is generally advised (NHS Choices
2009). Delayed introduction of eggs beyond
this age may be counterproductive. In a
cross-sectional survey, 2,589 infants took part
in skin-prick tests to establish sensitisation to egg
white, with positive responders being invited to
take an oral food challenge with eggs. Parents
were asked to complete a questionnaire about
infant feeding practices. The results showed that
infants introduced to eggs after the age of ten
months were 60% more likely to develop an egg
allergy than infants who were fed eggs when aged
between four and six months (Koplin et al 2010).
Complete time out activity 6
Advising patients
As eggs are a commonly consumed, low-cost
food, mothers may be interested to know how
best to include them in the diet and whether
they should be aware of any limitations or safety
points. A previous review summarised relevant
advice about eggs from government websites,
highlighting that eggs are widely recommended
as part of a healthy, balanced diet because
of their rich nutrient content (Ruxton 2010).
Food safety remains important, and nurses can
promote this by suggesting that patients choose
eggs with a Lion Quality Code of Practice
mark, keep eggs in the fridge, observe use by
and best-before dates, and wash their hands
before and after handling egg shells. Regarding
risk of allergy, evidence suggests that cooked
eggs should be introduced once infants reach
six months of age, perhaps as scrambled eggs
or eggy bread. Waiting longer to introduce eggs
appears to offer no benefit and may increase the
risk of egg allergy.
For pregnant women, eggs are a useful source
of folate, vitamin D, iodine, selenium, choline
and omega-3 fatty acids (Figure 1). During
weaning, one egg provides significant levels
of several key vitamins and minerals (Figure 2).
The vitamin D content of eggs is particularly
important given that vitamin D deficiency
affects 19% of women of childbearing age
and few natural sources of vitamin D exist.
The compact size of eggs is relevant because
a medium-size egg, at 58g and 66kcal, is suitable
08/02/2013 12:22
 for very young infants and toddlers with small
appetites. The portion control represented by
one or two eggs may also be helpful for women
attempting to manage weight gain during
pregnancy, or weight loss following pregnancy.
Emerging research suggests a benefit on reported
satiety, and gut hormones that control hunger,
when eggs are eaten at breakfast or lunch
(Ruxton 2012).
Conclusion
Eggs are now more nutrient-dense than ever
and can make an important contribution
to the diets of pregnant women and infants.
The nutritional value of eggs is based on
new compositional data from the DH,
and emphasises the value of selected
nutrients in eggs to pregnant women and
young children.
In particular, this article has reviewed the
roles of vitamin D, folate, iodine, selenium,
choline, omega-3 fatty acids, vitamin A,
and phosphorus in maternal health, fetal
development, weight management during
pregnancy, and the growth and development
of infants NS
Complete time out activity 7

References
Arterburn LM, Hall EB, Oken H
(2006) Distribution, interconversion,
and dose response of n3 fatty acids in
humans. American Journal of Clinical
Nutrition. 83, 6 Suppl, 1467S1476S.
Barbour RS, Macleod M, Mires G,
Anderson AS (2012) Uptake of folic
acid supplements before and during
pregnancy: focus group analysis of
womens views and experiences.
Journal of Human Nutrition and
Dietetics. 25, 2, 140-147.
Barker DJ, Eriksson JG, Forsn T,
Osmond C (2002) Fetal origins of
adult disease: strength of effects
and biological basis. International
Journal of Epidemiology. 31, 6,
1235-1239.
Bender DA (2002) The vitamins. In
Gibney MJ, Vorster HH, Kok FJ (Eds)
Introduction to Human Nutrition.
Blackwell, Oxford, 125-176.
Brannon PM (2012) Vitamin D
and adverse pregnancy outcomes:
beyond bone health and growth.
Proceedings of the Nutrition Society.
71, 2, 205-212.
Calder PC, Kremmyda LS,
Vlachava M, Noakes PS, Miles EA
(2010) Is there a role for fatty acids
in early life programming of the
immune system? Proceedings of the
Nutrition Society. 69, 3, 373-380.
Chief Medical Officers of the UK
(2012) Vitamin D Advice on
Supplements for at Risk Groups.
The Stationery Office, London.
Crozier SR, Harvey NC, Inskip HM
et al (2012) Maternal vitamin D
status in pregnancy is associated
with adiposity in the offspring:
findings from the Southampton
Womens Survey. American Journal
of Clinical Nutrition. 96, 1, 57-63.
Department of Health (1991)
Dietary Reference Values for
Food Energy and Nutrients for the
United Kingdom. Report on Health
and Social Subjects no. 41. The
Stationery Office, London.
Department of Health (2012)
Nutrient Analysis of Eggs. The
Stationery Office, London.
Derbyshire E (2011a) Macronutrients
and pregnancy. In Derbyshire E
Nutrition in the Childbearing Years.
Wiley-Blackwell, Oxford, 100-125.
Derbyshire E (2011b) Preparing the
body for pregnancy. In Derbyshire E
Nutrition in the Childbearing Years.
Wiley-Blackwell, Oxford, 25-49.
Derbyshire E (2011c) Vitamins
and pregnancy. In Derbyshire E
Nutrition in the Childbearing Years.
Wiley-Blackwell, Oxford, 126-148.
Derbyshire E (2011d) Minerals
and pregnancy. In Derbyshire E
Nutrition in the Childbearing Years.
Wiley-Blackwell, Oxford, 149-167.
Derbyshire E (2011e) Special cases.
In Derbyshire E Nutrition in the
Childbearing Years. Wiley-Blackwell,
Oxford, 218-240.
Eilander A, Hundscheid DC,
Osendarp SJ, Transler C, Zock PL
(2007) Effects of n-3 long chain
polyunsaturated fatty acid
supplementation on visual and
cognitive development throughout
childhood: a review of human
studies. Prostaglandins,
Leukotrienes, and Essential Fatty
Acids. 76, 4, 189-203.
Emmett PM, Rogers IS (1997)
Properties of human milk and their
relationship with maternal nutrition.
Early Human Development. 49,
S7-S28.
European Commission (2008)
Commission Directive 2008/100/
EC of 28 October 2008 Amending
Council Directive 90/496/EEC on
Nutrition Labelling for Foodstuffs
as Regards Recommended Daily
Allowances, Energy Conversion
Factors and Definitions. tinyurl.
com/5hss4b (Last accessed:
January 16 2013.)
European Commission (2012)
Commission regulation (EU)
No 432/2012 of 16 May 2012
Establishing a List of Permitted
Health Claims made on Foods, Other
than those Referring to the Reduction
of Disease Risk and to Childrens
Development and Health. tinyurl.com/
ceacoto (Last accessed:
January 16 2013.)
European Food Safety Authority
(2006) Preliminary Report on
Analysis of the Baseline Study on the
Prevalence of Salmonella in Laying
Hen Flocks of Gallus gallus. tinyurl.
com/d3bq8ww (Last accessed:
January 16 2013.)
Food Standards Agency (2004)
Report of the Survey of Salmonella
Contamination of UK Produced Shell
Eggs on Retail Sale. FSA, London.
Food Standards Agency, Department
of Health (2012) National Diet and
Nutrition Survey: Headline Results
from Years 1, 2 and 3 (Combined) of
the Rolling Programme (2008/2009-
2010/11). The Stationery Office,
London.
Garza C, Rasmussen KM (2000)
Pregnancy and lactation. In Garrow
JS, James WPT, Ralph A (Eds) Human
Nutrition and Dietetics. Churchill
Livingstone, London, 437-448.
Gray J, Griffin B (2009) Eggs and
dietary cholesterol dispelling the
myth. Nutrition Bulletin. 34, 1, 66-70.
Gupta R, Lau CH, Springston EE
et al (2012) Childhood food allergy
tolerance and associated factors
(Abstract FP18). Annals of Allergy,
Asthma and Immunology, 109, 5,
Suppl.
Health Protection Agency (2011)
Salmonella Enteritidis PT 14b
Investigation Latest. tinyurl.com/
cvrxcoj (Last accessed:
January 16 2013.)
Helland IB, Smith L, Saarem K,
Saugsted OD, Drevon CA (2003)
Maternal supplementation with
very-long-chain n-3 fatty acids
during pregnancy and lactation
augments childrens IQ at 4 years
of age. Pediatrics. 111, 1, e39-e44.
Heslehurst N, Ells LJ, Simpson H,
Batterham A, Wilkinson J,
Summerbell CD (2007) Trends in
maternal obesity incidence rates,
demographic predictors, and health
inequalities in 36,821 women over
a 15-year period. BJOG: An
International Journal of Obstetrics
and Gynaecology. 114, 2, 187-194.
Holick MF (1996) Vitamin D and
bone health. Journal of Nutrition.
126, 4, Suppl, 1159S-1164S.

NURSING STANDARD / RCN PUBLISHING february 13 :: vol 27 no 24 :: 2013 49

p41-50w24.indd 49 08/02/2013 12:22

 Learning zone nutrition
Holland B, Unwin ID, Buss DH
(1989) Milk Products and Eggs:
Fourth Supplement to McCance and
Widdowsons The Composition of
Foods. Royal Society of Chemistry,
Cambridge.
Holmes VA, Barnes MS,
Alexander HD, McFaul P, Wallace JM
(2009) Vitamin D deficiency and
insufficiency in pregnant women:
a longitudinal study. British Journal
of Nutrition. 102, 6, 876-881.
Huffman SL, Harika RK, Eilander A,
Osendarp SJ (2011) Essential
fats: how do they affect growth
and development of infants and
young children in developing
countries? A literature review.
Maternal and Child Nutrition.
7, Suppl 3, 44-65.
Hyppnen E, Lr E, Reunanen A, Shell Eggs on Retail Sale in the
Jrvelin AR, Virtanen SM (2001)
Intake of vitamin D and risk of type 1
diabetes: a birth-cohort study.
The Lancet. 358, 9292, 1500-1503.
Inskip HM, Crozier SR, Godfrey KM
et al (2009) Womens compliance
with nutrition and lifestyle
recommendations before pregnancy:
general population cohort study.
British Medical Journal (Clinical
Research edition). doi:10.1136/
bmj.b481.
Institute of Medicine (2010) Dietary
Reference Intakes for Calcium and
Vitamin D. tinyurl.com/2vyyay5
(Last accessed: January 16 2013.)
Javaid MK, Crozier SR, Harvey NC
et al (2006) Maternal vitamin D
status during pregnancy and
childhood bone mass at age 9 years:
a longitudinal study. The Lancet.
367, 9504, 36-43.
Jiang X, Yan J, West AA et al (2012)
Maternal choline intake alters
the epigenetic state of fetal
cortisol-regulating genes in humans.
FASEB Journal. 26, 8, 3563-3574.
Kibirige MS, Hutchison S, Owen CJ,
Delves HT (2004) Prevalence of
maternal dietary iodine insufficiency
in the north east of England:
implications for the fetus. Archives
of Disease in Childhood. Fetal and
Neonatal edition. 89, 5, F436-F439.
Knip M, Virtanen SM, Akerblom HK
(2010) Infant feeding and the risk
of type 1 diabetes. American
Journal of Clinical Nutrition.
91, 5, 1506S-1513S.
50 february 13 :: vol 27 no 24 :: 2013 NURSING STANDARD / RCN PUBLISHING
p41-50w24.indd 50
Koletzko B, Brands B, Poston L,
Godfrey K, Demmelmair HL, Early
Nutrition Project (2012) Early
nutrition programming of long-term
health. Proceedings of the Nutrition
Society. 71, 3, 371-378.
Koplin JJ, Osborne NJ, Wake M et al
(2010) Can early introduction of egg
prevent egg allergy in infants? A
population-based study. Journal of
Allergy and Clinical Immunology.
126, 4, 807-813.
Lawson M, Thomas M (1999) Vitamin
D concentrations in Asian children
aged 2 years living in England:
population survey. British Medical
Journal. 318, 7175, 28.
Little CL, Walsh S, Hucklesby L et al
(2006) Survey of Salmonella
Contamination of Non-UK Produced
Nursing Standard. 24, 37, 47-55.
North West of England and London.
Food Standards Agency, London.
Lozoff B (2011) Early iron deficiency
has brain and behavior effects
consistent with dopaminergic
dysfunction. Journal of Nutrition.
141, 4, 740S-746S.
Medical Research Council (2012)
Diet and Nutrition Survey of Infants
and Young Children. MRC Human
Nutrition Research, Cambridge.
Mistry HD, Kurlak LO, Young SD
et al (2012) Maternal selenium,
copper and zinc concentrations in
pregnancy associated with
small-for-gestational-age infants.
Maternal and Child Nutrition. (Epub
ahead of print) doi: 10.1111/j.
1740-8709.2012.00430..
Nelson M, Erens B, Bates B,
Church S, Boshier T (2007) Low
Income Diet and Nutrition Survey.
The Stationery Office, London.
NHS Choices (2009) Babies,
Weaning What to Avoid. tinyurl.
com/c7mkogo (Last accessed:
January 16 2013.)
NHS Choices (2011) Eggs. tinyurl.
com/d46vvj8 (Last accessed:
January 16 2013.)
Ratliff J, Leite JO, de Ogburn R,
Puglisi MJ, VanHeest J,
Fernandez ML (2010) Consuming
eggs for breakfast influences
plasma glucose and ghrelin, while
reducing energy intake during the
next 24 hours in adult men.
Nutrition Research. 30, 2, 96-103.
Rayman MP, Wijnen H, Vader H,
Kooistra L, Pop V (2011) Maternal
selenium status during early
gestation and risk for preterm birth.
Canadian Medical Association
Journal. 183, 5, 549-555.
Rees GA, Doyle W, Srivastava A,
Brooke ZM, Crawford MA,
Costeloe KL (2005) The nutrient
intakes of mothers of low birth weight
babies: a comparison of ethnic groups
in East London, UK. Maternal and
Child Nutrition. 1, 2, 91-99.
Rona RJ, Keil T, Summers C et al
(2007) The prevalence of food
allergy: a meta-analysis. Journal of
Allergy and Clinical Immunology.
120, 3, 638-646.
Ruxton C (2010) Recommendations
for the use of eggs in the diet.
Thomas B (2001) Manual of Dietetic
Ruxton CHS (2011) The benefits of
fish consumption. Nutrition Bulletin.
36, 1, 6-19.
Ruxton C (2012) Eggs and satiety.
Network Health Dietitian. 76, July,
7-8.
Ruxton CHS, Derbyshire E (2009)
Health impacts of vitamin D: are we
getting enough? Nutrition Bulletin.
34, 2, 185-197.
Ruxton CHS, Derbyshire E (2010)
Womens diet quality in the UK.
Nutrition Bulletin. 35, 2, 126-137.
Saltzman RW, Kelleher M,
Spergel JM (2012) Baked egg oral
food challenges: a single-center
pediatric hospital experience
(Abstract FP10). Annals of Allergy,
Asthma and Immunology, 109, 5
Suppl.
Scientific Advisory Committee on
Nutrition (2003) Vitamin D Deficiency
in Children. Agenda item 2, paper for
discussion. SACN, London.
Scientific Advisory Committee on
Nutrition (2011a) Draft Selenium
and Health Position Statement.
SACN, London.
Scientific Advisory Committee on
Nutrition (2011b) The Influence of
Maternal, Fetal and Child Nutrition
on the Development of Chronic
Disease in Later Life. SACN, London.
Scientific Advisory Committee on
Nutrition and Committee on Toxicity
(2004) Advice on Fish Consumption:
Benefits and Risks. The Stationery
Office, London.
Shaw GM, Finnell RH, Blom HJ et al
(2009) Choline and risk of neural
tube defects in a folate-fortified
population. Epidemiology. 20, 5,
714-719.
Smith R (2000) Bone mineral. In
Garrow JS, James WPT, Ralph A
(Eds) Human Nutrition and Dietetics.
Churchill Livingstone, London.
165-176.
Thangaratinam S, Rogozinska E,
Jolly K et al (2012) Effects of
interventions in pregnancy on
maternal weight and obstetric
outcomes: meta-analysis of
randomised evidence. British
Medical Journal. 344, e2088.
Practice. Third edition. Blackwell
Publishing, Oxford.
Trang HM, Cole DE, Rubin LA,
Pierratos A, Siu S, Vieth R (1998)
Evidence that vitamin D3 increases
serum 25-hydroxyvitamin D more
efficiently than does vitamin D2.
American Journal of Clinical
Nutrition. 68, 4, 854-858.
Vander Wal JS, Gupta A, Khosla P,
Dhurandhar NV (2008) Egg
breakfast enhances weight loss.
International Journal of Obesity.
32, 10, 1545-1551.
Walker VP, Modlin RL (2009) The
vitamin D connection to pediatric
infections and immune function.
Pediatric Research. 65, 5 Pt 2,
106R-113R.
Westermarck T, Antila E (2000)
Diet in relation to the nervous
function. In Garrow JS, James WPT,
Ralph A (Eds) Human Nutrition and
Dietetics. Churchill Livingstone,
London, 715-730.
Zeisel SH (2009) Importance of
methyl donors during reproduction.
American Journal of Clinical
Nutrition. 89, 2, 673S-677S.
Zeisel SH (2011) Nutritional
genomics: defining the dietary
requirement and effects of choline.
Journal of Nutrition. 141, 3, 531-534.
Zeisel SH, Mar MH, Howe JC,
Holden JM (2003) Concentrations of
choline-containing compounds and
betaine in common foods. Journal of
Nutrition. 133, 5, 1302-1307.
08/02/2013 12:22
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