NCM 105: NUTRITION AND DIET THERAPY

MIDTERMS
Unit Five. NUTRITION THROUGHOUT THE
LIFESPAN
Chapter 1: Pregnancy
A. Stages
B. Nutritional Problems and Interventions
C. Recommended Diet

Chapter 2: Lactation
A. Common Nutritional Problems
B. Recommended Diet

Chapter 3: Infancy
A. Recommended Diet
B. Factors Affecting Nutritional Status
C. Guidelines in Feeding
D. Nutritional Problems and Intervention

Chapter 4: Toddlers
A. Nutritional Problems and Interventions
B. Guidelines in Feeding
C. Recommended Diet

Chapter 5: Pre-School and Schoolers

A. Nutritional Problems and Interventions
B. Guidelines in Feeding
C. Recommended Diet

Chapter 6: Adolescent
A. Nutritional Problems and Interventions
B. Recommended Diet

Chapter 7: Adulthood
A. Nutritional Problems and Interventions
B. Recommended Diet

Chapter 8: Elderly
A. Nutritional Problems and Interventions
B. Recommended Diet
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MIDTERMS UNIT FIVE. NUTRITION THROUGHOUT THE LIFESPAN

CHAPTER 1: PREGNANCY
A. STAGES

Pregnancy – (Gestation) is a period when the fertilized ovum implants itself in the uterus. Human pregnancy last for the
period of 266 – 180 days (37-40 weeks)

Nutritional Needs During Pregnancy

Facts
Good nutrition in pregnancy essential for mother and child
Relationship between mothers’ diet and health of baby at birth

Nutrition Prior to Pregnancy

Both a man’s and a woman’s nutrition may affect fertility and possibly the genetic contributions they make to their
children, but it is the woman’s nutrition that has the most direct influence on the developing fetus. Her body provides the
environment for the growth and development of a new human being. Prior to pregnancy, however, both men and women
have a unique opportunity to prepare physically, mentally, and emotionally for the many changes to come.

In preparation for a healthy pregnancy, they can establish the following habits:
Achieve and maintain a healthy body weight. Both underweight and overweight are associated with infertility.
Overweight and obese men have low sperm counts and hormonal changes that reduce fertility.
Excess body fat in women disrupts menstrual regularity and ovarian hormone production.
Should a pregnancy occur, mothers, both underweight and overweight, and their newborns, face increased risks of
complications.
Choose an adequate and balanced diet. Malnutrition reduces fertility and impairs the early development of an infant
should a woman become pregnant.
In contrast, a healthy diet that includes a full array of vitamins and minerals can favorably influence fertility.
Men with diets rich in antioxidant nutrients and low in saturated fats have higher sperm numbers and motility.
Be physically active. A woman who wants to be physically active when she is pregnant needs to become physically active
beforehand.
Receive regular medical care. Regular health care visits help ensure a healthy start to pregnancy.
Manage chronic conditions. Conditions such as diabetes, hypertension, HIV/
AIDS, phenylketonuria (PKU), and sexually transmitted diseases can adversely affect a pregnancy and need close medical
attention to help ensure a healthy outcome.
Avoid harmful influences. Both maternal and paternal ingestion of, or exposure to, harmful substances (such as cigarettes,
alcohol, drugs, or environmental contaminants) can cause miscarriage or abnormalities, alter genes or their expression,
and may interfere with fertility.

Bad diet can cause:

Modify normal diet to meet needs of pregnant and lactating women
Premature birth
Low birth weight
Feeble, weak
Inability to breast feed Deformed
babies complications at birth
Depression
Babies have fewer brain cells

Metabolic changes
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.
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.
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Increased macronutrient and micronutrient intake by the mother during pregnancy ensures that these increased metabolic
needs are met.

Physiology of Pregnancy
Pregnancy averages 38 weeks, or 266 days, in length
Commonly, pregnancy duration is given as 40 weeks (280 days) because it is measured from the date of the first day of the
last menstrual period (LMP)
Normal Physiological Changes During Pregnancy
First half : “maternal anabolic” deliver relatively large quantities of blood, oxygen 10% of fetal growth in the first
half of pregnancy
Second half : “maternal catabolic”, which energy and nutrient stores, deliver stored energy and nutrients to the fetus,
fetal growth90% occurs in the second half

1. Body Water Changes

A woman’s body water ↑↑ during pregnancy = increased volumes of plasma and extracellular fluid, as well as amniotic
fluid Body water (2)
Plasma volume begins to increase after conception and reaches a maximum at ± 34 weeks
Plasma-volume increases : primary reason that pregnant woman feel tired and become exhausted easily, make pregnant
woman fatigue in second and third trimester
Body water (3)
Birth weight strongly related to plasma volume generally, the greater the expansion, the greater the newborn size
The increased volume of water in the blood is responsible for the “dilution effect” of pregnancy decreased levels of
hemoglobin, serum albumin, other serum protein and water soluble vitamin
2. Cardiovascular and Pulmonary Function
Increased cardiac output and cardiac size
Pressure of the expanding uterus on the inferior vena cava Mild lower extremity edema
Blood return to the heart decrease cardiac output ↓, fall in blood pressure , and lower-extremity edema
Maternal oxygen requirements increase
3. Gastrointestinal function
First trimester : Nausea and Vomiting
Increased Progesterone level
Relaxed lower esophageal sphincter and pressure on the stomach from the growing uterus--regurgitation and gastric reflux
Gall bladder emptying becomes less efficient
4. Renal Function
The Glomerular Filtration Rate increases by 50%
Renal tubular resorption is less efficient than in the nonpregnant state
Glucosuria (+) – increase the risk for urinary tract infections
5. Hormonal Changes
The placenta serves many roles, but a key one is the production of steroid hormones such as progesterone and
estrogen.
The placenta : main supplier of hormones needed to support the physiological changes of pregnancy Hormonal Changes
(2)
6. Maternal Nutrient Metabolism
Carbohydrate Metabolism
Glucose is the fetus’s preferred fuel
Carbohydrate metabolism in the first half of pregnancy is characterized by estrogen- and progesterone-stimulated
increases in insulin production and conversion of glucose to glycogen and fat.
Carbohydrate Metabolism
In the second half, rising levels of hCS and prolactin from the mother’s pituitary gland inhibit the conversion of glucose
to glycogen and fat
At the same time, insulin resistance builds in the mother, increasing her reliance on fats for energy Protein Metabolism
Nitrogen and protein needed >> for synthesis of new maternal and fetal tissues
To some extent the increased need for protein is met through reduced levels of nitrogen excretion and the conservation of
amino acids for protein tissue synthesis
Fat Metabolism
Plasma triglyceride = three times non pregnant levels
Cholesterol containing lipoprotein, phospolipid, and fatty acid also increase, but lesser than triglycerides
Cholesterol supply used by placenta for steroid hormone synthesis and by the fetal for nerve and cell membrane formation
Mineral Metabolism
Calcium metabolism characterized by increased rate of bone turnover and reformation
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↑↑ levels of body water and tissue synthesis -- increased requirements for sodium
Sodium metabolism delicately balance by changes in the kidneys that increase aldosterone secretion and the retention of
sodium
7. The Placenta
Placenta derived from Latin word for cake.
Metabolically active organ
• Requires energy and nutrients
• Produces hormones
Functions of the placenta include:
● Hormone and enzyme production,
● Nutrient and gas exchange between the mother and fetus
● Removal of waste products from the fetus
Prevents passage of red blood cells, bacteria, and large proteins from mother

The Zygote The newly fertilized ovum is called a zygote. It begins as a single cell and rapidly divides to become a
blastocyst. During that first week, the blastocyst floats down into the uterus, where it will embed itself in the inner uterine
wall— a process known as implantation. Cell division continues at an amazing rate as each set of cells divides into many
other cells.
The Embryo At first, the number of cells in the embryo doubles approximately every 24 hours; later the rate slows, and
only one doubling occurs during the final 10 weeks of pregnancy. At 8 weeks, the 1¼inch embryo has a complete central
nervous system, a beating heart, a digestive system, well-defined fingers and toes, and the beginnings of facial features.
The Fetus The fetus continues to grow during the next 7 months. Each organ grows to maturity according to its own
schedule, with greater intensity at some times than at others. Fetal growth is phenomenal: weight increases from less than
an ounce to about 7½ pounds (3500 grams). Most successful pregnancies are full term—defined as births occurring at 39
through 40 weeks—and produce a healthy infant weighing 6½ to 8 pounds.

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 absorption, a still birth, or low birth weight infant.
One of the result of this increase in plasma volume is a hemodilution effect.
In other words, measured components in the plasma such as hemoglobin, serum proteins, and vit will appear to be lower
levels during pregnancy because there is 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.
Weight gain in pregnancy
 NCM 105: NUTRITION AND DIET THERAPY

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 required prolonged hospitalization
after birth or be ill or die during 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.
Recommended total weight gain ranges for pregnant women, by prepregnancy body mass index (bmi)

Critical Periods Times of intense development and rapid cell division are called critical periods—critical in the sense that
those cellular activities can occur only at those times. If cell division and number are limited during a critical period, full
recovery is not possible. Damage during these critical times of pregnancy has permanent consequences for the life and
health of the fetus.

The development of each organ and tissue is most vulnerable to adverse influences (such as nutrient
deficiencies or toxins) during its own critical period.
The neural tube, for example, is the structure that eventually becomes the brain and the spinal cord, and its critical period
of development is from 17 to 3 days of gestation. Consequently, neural tube development is most vulnerable to nutrient
deficiencies,
Nutrient excesses, or toxins during this critical time—when most women do not yet even realize they are pregnant.
Any abnormal development of the neural tube or its failure to close completely can cause a major defect in the central
nervous system.
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Weight Gain
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Distribution of Weight Gain

AREA
Fetus
Stores of Fat & Protein
Blood
Tissue Fluids
Uterus
Amniotic Fluid
Placenta & Cord
Breasts
Affect on body
Increased clumsiness
Backache are the most common.
 NCM 105: NUTRITION AND DIET THERAPY

Many women complain of leg- and ankle-swelling (edema), but this symptom is actually caused by the extra amount of
blood in your body, not fat.
Recommended Daily Allowance:

Guide to Good Eating During Pregnancy

Milk-Cheese Group - 3 servings (Pregnant Teens: add 1 serving)
Count as 1 serving: 1 cup milk, 1 1/2 cup cottage cheese; 2 cups ice cream; 2, 1-inch cubes cheese.
Meat, Poultry, Fish and Beans - 3 servings
Count as one serving: 2 to 3 ounces meat, fish or poultry; 2 eggs; 2 slices lunch meat; 4 Tbls. peanut butter; 1 cup kidney,
pinto or garbanzo beans
Fruit Group - 3 servings (Pregnant Teens: add 1 serving)
Count as 1 serving: 3/4 cup juice; 1 medium banana, apple or orange.
Vegetable Group - 4 servings (Pregnant Teens: add 1 serving)
Count as 1 serving: 1/2 cup cooked vegetables; 1 cup raw leafy vegetables; 3/4 cup juice.
Include every day:
1 rich Vitamin C source such as citrus fruit and 1 dark green leafy vegetable.
Bread and Cereals Group - 9 servings (Pregnant Teens: add 1 to 2 servings)
Count as 1 serving: 1 slice bread; 1-ounce ready-to-eat cereal; 1/2 to 3/4 cup cooked cereal or pasta.
Fats, Oils and Sweets Group - Use Sparingly
Count as 1 serving: 1 Tbl. corn, safflower or cottonseed oil used in cooking or in salad dressing; 1 Tbl. butter or
margarine.
Cakes, pies, cookies, soft drinks, sugar, honey, candy, jams, jellies, gravies, butter, sour cream - Save these to eat only if
you need extra calories after eating the basic needed foods.

“fast” food
1. Single serve fruit bowls
2. Soy milk
3. Tuna fish
4. Raisins
5. Yogurt
6. Easy-to-make trail mix
7. Salad Bar
8. Baby carrots
9. String Cheese
10. Boxed, calcium fortified orange juice
11. Single-serve boxes of cereal
12. Single-serve cottage cheese bowl

Foods to avoid:
1. Ramen Noodles
2. Sodas
3. Pre-packaged lunches (like lunchables)
4. Almost all prepared, frozen meals
5. Iceberg lettuce

Exercise during Pregnancy

Reduces fatigue and helps manage stress
Increases endurance and strengthening muscles
Help relieve back pressure
Improve posture and balance
Improve circulation & lowers blood pressure Helps prepare
for the strain of labor.
Improve self-image.
Regain figure faster.

Exercise
Strenuous exercise was thought to divert blood to the exercising muscles and thus reduce the blood supply to the fetus.
If a woman chooses to exercise during pregnancy, she must remember to drink fluids before, after, and if necessary, during
exercise and to choose nutritious snacks before and after exercise. Exercises
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1. Stretches for lower back

2. Upper back stretch
3. Pelvic Tilts
4. Kegels
Swimming

Nutritional Needs during Pregnancy

Folic acid supplementation prior to conception decreases risk of brain and spinal cord defects
Protein requirement increased by 20 percent for pregnant woman over age 25
25 percent for pregnant adolescent
Excess vitamin A can cause birth defects

Nutritional Needs during Pregnancy

Requirements for the following increased:
All water-soluble vitamins
Vitamin B and vitamin C
Calcium, iron, zinc, iodine, and selenium
Iron supplements commonly prescribed due to drastic increase in needs

Nutrition in Pregnancy:
During the total pregnancy period, the basal metabolic rate increase from 6-14%
Calorie intake is increased – 10-20% increase ( if the woman is overweight it is necessary for her o reduce)
Protein - Increase in nitrogen content of the fetus and its membranes and added protection of the mother against
complications Increase of 9.5 gms./ day
Calcium / Phosphorus / Vit. D – Increase , to calcify the fetal bones & teeth (0.5 – 0.9 of the RDA)
Iron – Increase, 700-1000 mg. of Fe is absorbed during the pregnancy
Iodine – to help the mother and the child prevent goiter in the future and for brain development Folic Acid - women of
childbearing age consume 400 micrograms (0.4 mg) of folic acid each day. Folic acid, a nutrient found in some green,
leafy vegetables, most berries, nuts, beans, citrus fruits, fortified breakfast cereals, and some vitamin supplements can help
reduce the risk of birth defects of the brain and spinal cord (called neural tube defects).

Fulfillment of Nutritional Needs during Pregnancy

Base diet on MyPyramid
Drink additional fat-free milk or appropriate substitute
Prenatal vitamins and iron supplement may be prescribed
Over-the-counter nutrient supplements may be harmful to fetus
Energy and nutrient needs during pregnancy
The dietary reference intakes (DRIs) recommend increases during pregnancy of all nutrients EXCEPT Including
 NCM 105: NUTRITION AND DIET THERAPY

phosphorus, fluoride, calcium, and biotin. There are separate dietary recommendations for adolescents who are pregnant.
DRIs to Meet Needs of Pregnancy and Lactation
Energy
Best estimates energy cost of pregnancy is somewhere between 68,000 kcal and 80,000 kcal. Increase accommodates the
rise in maternal BMR during pregnancy as well as the synthesis and support of the maternal and fetal tissues.
The current recommendation is for woman to consume an extra 300 kcal per day during the 2 nd and 3rd trimesters of
pregnancy.
Extra sandwich and a glass of milk can easily provide the additional 300 kcal per day, providing she was eating well
before pregnancy.
PROTEINS
Recommended Dietary Allowance (RDA) for protein during pregnancy is 60 grams per day for adolescent and adult
women.
Pregnant Patients may be counceled to include appropriate sources of protein that provides vit, minerals, and moderate
amounts of fat.
Changes in the daily food guide pyramid during pregnancy and lactation
Vitamin and mineral supplementation
The DRIs are increased during pregnancy for most vitamins A and D.
Micronutrient needs may be met with a balanced diet, with a few notable exceptions including folate and iron.
All supplementation during pregnancy should be in the form of prenatal type multivitamin mineral supplements are
recommended by primary healthcare providers or dieticians.
Folate. 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.
Iron. The RDA for iron during pregnancy is 30 mg/day. This level may be difficult to achieve with a normal diet, which
maintains recommended fat and kcaloric guidelines.
Therefore all woman should take a supplement with 30mg ferrous iron daily beginning in the 2 nd trimester to prevent
iron deficiency anemia in pregnancy.
Iron deficiency anemia
✓ one of the most common complications of pregnancy.
✓ Can mean impaired oxygen delivery to the fetus, which may have severe consequences.
In addition, during the last trimester, the fetus stores iron in its liver to use during the 1 st 4months of life.
Pica
✓ Characterized by a hunger and appetite for non-food substances including ice, corn starch, clay, and even dirt.
✓ These substances contain no iron and may lead to loss of additional minerals, particularly when clay and dirt are
consumed.
✓ Intestinal blockages caused by consumption of these substances may be life-threatening. Calcium. The Adequate
Intake (AI) for calcium is 1000 mg/day for women and 1300 mg/day for adolescents, neither of which is an
increase over the non-pregnant state.
Although calcium needs are great during pregnancy, particularly for mineralization of the fetal skeleton, changes
occur in maternal calcium homeostasis, which results in an increase in intestinal calcium absorption.
Nutrition-related concerns
A number of non-nutritive substances that women may be exposed to during pregnancy may have the capability to act as
teratogens.
Teratogen an agent capable of producing a malformation or a defect in the unborn fetus. Some anomalies are
apparent at birth or shortly after, such as NTDs or a cleft lip or palate.
Cleft lip or palate
Other defects such as delayed growth or learning deficits may not be noticeable for several months or even years.
Potential teratogens include caffeine, drugs, alcohol, and tobacco.
Other concerns affecting the course and outcome of pregnancy include strenuous exercise, maternal age, and medical
conditions requiring nutrition intervention such as hypertension, diabetes, phenylketonuria, and human immunodeficiency
virus (HIV) infection.

Guidelines for exercise during pregnancy:

✓ Limit workouts to 15 mins.
✓ Keep pulse rate below 140 bpm
✓ Drink plenty of fluids before, after, during exercise.
✓ Do not exercise lying in your back after the fourth month.
✓ Avoid exercising in hot, humid weather.
✓ Consume enough kcal to meet the extra needs of pregnancy plus the exercise performed.
 NCM 105: NUTRITION AND DIET THERAPY

Indicator of Nutritional Status in Pregnancy

Several Indicator of Nutritional Status in Pregnancy : Upper arm muscle circumference, weight for height and eating
patterns (weight gain), Hemoglobin.
Weight Gain During Pregnancy
Weight Gain
Upper Arm Circumference
Nutritional Assessment for Breastfeeding Women
Nutrition Requirement
Factors affecting nutrient requirements during pregnancy:
- pre pregnancy nutrient stores
- body size and composition
- physical activity levels - stage of pregnancy - health status.

The need for energy

Energy requirements increase during pregnancy, mainly due to increased maternal body mass and fetal growth.
The increased need for energy in pregnancy averages 300 kcal a day.
The increased calorie need in pregnancy:
1/3 → increased work of the heart
1/3 → increased energy needs for respiration and accretion of breast tissue, uterine muscles, and the placenta
1/3 → the fetus

The need for carbohydrate

Approximately 50–60% of total caloric intake during pregnancy should come from carbohydrates.
Women should consume a minimum of 175 grams carbohydrates to meet the fetal brain’s need for glucose.

The need for protein

The recommended protein intake for pregnancy is +25 grams per day. Less protein is used for energy and more is used
for protein synthesis.
Approximately 925 grams of protein (2 pounds) accumulated in protein tissues during pregnancy
- 440 grams are taken up by the fetus
- 216 grams are used for increases in maternal blood and extracellular fluid volume
- 166 grams are consumed by the uterus
- 100 grams are accumulated by the placenta.

The need for fat

It is estimated that pregnant women consume 33% of total calories from fat.
Used as an energy source for fetal growth and development and serves as a source of fatsoluble vitamins.
Fat also provides essential fatty acids that are specifically required for components of fetal growth and development.
The need for water
On average, women consume about 9 cups of fluid daily during pregnancy (+300 mL a day). Women who engage in
physical activity in hot and humid climates should drink enough to keep
urine light-colored and normal in volume. Water, diluted fruit juice, iced tea, and other unsweetened beverages are
good choices for staying hydrated.

Concerns during Pregnancy

Nausea
Constipation
Heartburn
Excessive weight gain
Pregnancy-induced hypertension
Pica
Anemia
Alcohol, caffeine, drugs, and tobacco
Nausea
Also known as morning sickness
Occurs most commonly during first trimester Suggestions:
Eat dry crackers or dry toast before rising
Eat small, frequent meals
Avoid food with offensive odors
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Avoid liquids at mealtime

Nausea

Hyperemesis gravidarum:
Occurs when nausea becomes so severe that it is life-threatening
May require hospitalization and parenteral nutrition
Constipation
Constipation and hemorrhoids can occur during pregnancy.

Suggestions:
Eat high-fiber diet
Participate in daily exercise
Drink at least 8 glasses of water per day
Respond promptly to urge to defecate

Heartburn
Can result from pressure on stomach by growing fetus and relaxation of cardiac sphincter and smooth muscles related to
progesterone.

Suggestions:
Eat small, frequent meals
Avoid spicy or greasy foods
Avoid liquids at mealtime
Wait at least one hour after eating to lie down and two hours before exercising

Excessive Weight Gain

Re-evaluate diet and eliminate foods that do not fit within MyPyramid

Suggestions:
Drink fat-free milk
Eat clean, crisp, raw vegetables as snack
Eat fruits and custards made with fat-free milk as desserts Broil, bake, or
boil instead of fry

Pregnancy-Induced Hypertension
Formerly known as pre-eclampsia or toxemia
Characterized by high blood pressure, presence of protein in urine, and edema in third trimester
May progress into eclamptic stage with convulsions, coma, and possible death of mother and infant

Pregnancy-Induced Hypertension
Higher incidence with first pregnancy, multifetal pregnancies, morbidly obese women, or women with inadequate diets
Especially protein-deficient
More frequent in pregnant adolescents

Pica
Craving for nonfood substances
E.g., starch, clay (soil), or ice
Discourage ingestion of soil due to possible contamination and nutrient deficiencies

Multiple nutritional deficiencies can result

Anemia
Condition caused by insufficiency of RBCs, hemoglobin, or blood volume Causes weakness,
fatigue, poor appetite, and pallor
Anemia
Iron-deficiency anemia
Most common form
Folate deficiency may lead to megaloblastic anemia
Prevented by folate supplement
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Alcohol, Caffeine, Drugs, and Tobacco

Alcohol
Use of alcohol during pregnancy may produce
Symptoms include
Fetal alcohol syndrome (FAS)
Or fetal alcohol spectrum disorder (FASD) in the infant.
Characterized by specific anatomic defects such as a low nasal bridge, short nose, flat midface, and short palpebral,
growth deficiency, central nervous system dysfunction, microcephaly, and other physical characteristics
Fetal alcohol effect (FAE)
Causes fewer physical defects but many behavioral and psychosocial problems Abstinence recommended

Caffeine
Whether a woman should refrain from caffeine consumption during pregnancy has been a matter of debate.
Caffeine (1-, 3-, 7-trimethyxanthine) may alter deoxyribonucleic acid (DNA) and, in some individuals, may alter
circulating levels of neurotransmitters and increase blood pressure.
However there is now enough evidence stating that caffeine is not a human teratogen, and even at modest doses (<300
mg/day or about 2 cups or less of coffee, there is no increased risk of spontaneous abortion or preterm labor.
Causes birth defects in rats, but no data exist for humans
Limit intake to < 300 mg per day

Drugs
Effect of prescription or self-prescribed drugs varies but includes possible damage to fetus
Vitamin A and its derivatives can cause fetal malformations and spontaneous abortions
A pregnant woman should not consume any cover-the-counter or prescription medications unless prescribed by her
primary healthcare provider.
Although not a direct nutrient concern, the acne medication isotretinoin (Accutane) contains high levels of retinoic acid in
the form of a vit A analogue.
Illegal drugs can cause infant to be born addicted or born with human immunodeficiency virus (HIV)

Tobacco
Women who smoke during pregnancy are at greater risk for several adverse outcomes including the following:
prematurity, low birth weight, SGA, stillbirth, placenta previa (location in lower uterine area), placentae abruptio
(separation from uterine wall), and postnatally, sudden infant death syndrome (SIDS).
Smoking during pregnancy may cause prolonged effects of impaired intellectual performance and decreased attention span
in the offspring.
Smoking associated with low birth weights, sudden infant death syndrome, fetal death, spontaneous abortions, and
complications at birth

Maternal age
Adolescents and women older than 35 years of age are at higher risk for poor pregnancy outcome. Women who become
pregnant after the age of 35 yrs have distinct nutritional needs, reflecting their longer medical history, potential long-term
use of oral contraceptives (which may affect folate levels) and the possibility of a longer history of poor eating habits.

Nutrition Problem in Pregnancy

Obesity and Pregnancy
Hypertensive Disorders of Pregnancy
Diabetes in Pregnancy
Multiple Pregnancies
Nutrition Problem in Pregnancy
Chronic Energy Impairment → 38,5% (LLA<23,5cm)
Anemia (37,1%)→ Hb<11
Eclampsia→ 24%
Malaria (1,9%) → tend to increase risks of: anemia, hemorrhage, LBW

Obesity and Pregnancy

Associated with : gestational diabetes & hypertensive disorders
Increase risks of: stillbirth, large-for-gestational newborns→ developing type 2 DM, Cesarean-section delivery
Comparative Prevalence of Obesity Prior to Pregnancy and Outcomes Related to Pregnancy
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Nutritional Recommendations and Interventions for Obesity During Pregnancy

Meeting nutrient needs + variety of basic foods
Changes in calorie intake and physical activity → weight gain (same as those for women of other sizes)
Monitoring and evaluation
Preeclampsia
Aka pregnancy-induced hypertension (PIH), is a complex syndrome of deficient vascularization, platelet
dysfunction, hyperlipidemia, and altered cytokine levels. Risk factors and symptoms of preeclampsia

PRE-PREGNANCY FACTORS THAT MAY LEAD TO THE DEVELOPMENT OF PREECLAMPSIA INCLUDE

THE FOLLOWING:
No previous pregnancies
Inadequate dietary intake
Diabetes mellitus (type1; type 2)
Age at conception: 20 years or younger
35 years or older
Family history: hypertension, vascular disease
Medical history of hypertension or renal or vascular disease
Preeclampsia in earlier pregnancies
Poverty that effects access to prenatal care
SYMPTOMS DURING PREGNANCY INCLUDE THE FOLLOWING:
Hypertension (changed compared with usual level)
Headaches (continuous and severe)
Dizziness and blurred vision
Edema of hands and face
Sudden weight gain
Upper abdominal pain
Slowed fetal growth
Protein in urine (proteinuria)
Hypertensive Disorders of Pregnancy
Related to chronic inflammation (oxidative stress, and damage to the endothelium)
Affect 6 to 10% → stillbirths, fetal and newborn deaths
Nutritional Recommendations and Interventions for Pre-eclampsia
Adequate Calcium (recommendation: 1000-2000 mg daily → 3x500 mg daily) and Vitamin-D (RDA intake for pregnant
women)
Intake of anti-oxidants (ex: Vit.E,vit.C)
Five or more servings of colorful vegetables and fruits daily
Consumption of the assortment of other basic food
Moderate exercise (walking, swimming, noncompetitive tennis, or dancing for 30 minutes) daily
→unless medically contraindicated
Weight gain
Diabetes in Pregnancy
7.5% of pregnant women, increasing along with obesity
Gestational diabetes accounts for 88% of all cases of diabetes in pregnancy
Diets developed for women with gestational diabetes
Whole-grain breads and cereals, vegetables, fruits, and high-fiber foods
Limited intake of simple sugars and foods and beverages that contain them
Low-GI foods, or high fiber carbohydrate foods that do not greatly raise glucose levels Unsaturated fats
Three regular meals and snacks daily
Estimating Levels of Caloric Need in Women with Gestational Diabetes

Multiple Pregnancy
Recommendation of Nutrition During Multiple Pregnancy
Anemia in pregnancy
Hb concentration <11 g/dL
-Increased maternal morbidity & mortality
-Increased fetal morbidity & mortality -
Increased risk of low birth weight Therapy :
Adequate intake of daily nutrition (heme-iron)
Iron supplement → 3x/daily (ferrous sulphate @300 mg→ metal element tablet @65 mg ), 2-3 months
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(+/- 90 tablets)

Diet for the Pregnant Woman with Diabetes

Some women have diabetes before pregnancy

Gestational diabetes
Occurs during pregnancy and disappears after birth
Routine screening part of prenatal care
Between 16 and 28 weeks
Insulin often used during pregnancy to control any type of diabetes

Nutrient requirements of pregnant woman with diabetes same as non-diabetic pregnant woman
Diet plan depends on type and number of insulin injections required
Artificial sweeteners found to be safe during pregnancy
Diabetes mellitus
Women with pre existing diabetes mellitus (DM) (type 1 and type 2 DM) requires specialized care during pregnancy.
Other complications include fetal macrosomia, dystocia, operative delivery, neonatal hypoglycemia and neonatal
respiratory distress syndrome.
Major defects;
Cardiac defects
Nervous system defects including NTDs Kidney
malformations,
And skeletal anomalies.
These infants may experience hypoglycemia after birth.
The maternal source of glucose is no longer available, and because glucose readily crosses the placenta, levels of glucose
in utero tend to be high, especially if the diabetes has been poorly controlled.
Current recommendation for women to achieve tight glucose control before conception ✓ Maximize the
likelihood of a healthy mother and infant, while avoiding perinatal risks.
✓ Control includes prudent blood glucose monitoring, adherence to diet, moderate exercise, and strict adherence to
the prescribed insulin regimen.
✓ Total energy intake and energy distribution will likely need modification during pregnancy because of the
increased energy needs of pregnancy.
✓ Insulin dosages will require adjustment because many of the hormones of pregnancy, such as estrogen,
progesterone, human chorionic, somatotropin, and maternal cortisol, act in an antagonistic fashion with insulin.

Pregnancy during Adolescence

Nutritional, physical, psychological, social, and economic demands on pregnant adolescents tremendous
Nutrition must meet needs of adolescent’s growing body and needs of fetus
High risk for pregnancy-induced hypertension and premature delivery
Pregnancy during Adolescence
Inadequate nutrition of mother related to both mental and physical birth defects
Much counseling and emotional support needed

CHAPTER 2: LACTATION
LACTATION PHYSIOLOGY
Mammary Gland
The functional units : alveoli
Each alveolus is composed of a cluster of cells (secretory cells) with a duct in the center Each smaller duct
leading to six to ten larger collecting ducts.
Myoepithelial cells surround the secretory cells can contract under the influence of oxytocin and cause milk to be ejected
into the ducts.
During puberty, the cyclic release of estrogen and progesterone governs pubertal breast development and usually complete
within 12 to 18 months after menarche.
Estrogen : stimulates development of the glands
Progesterone : elongate tubules and duplicate the cells that line the tubules (epithelial cells) Lactogenesis
Lactogenesis I, begins during the last trimester of pregnancy untill first day postpartum, milk begins to form, lactose and
protein content of milk increase
Lactogenesis II : 2–5 days postpartum, increased blood flow to the mammary gland
Lactogenesis III. This stage of breast milk production begins about 10 days after birth, the milk composition becomes
 NCM 105: NUTRITION AND DIET THERAPY

stable.
Hormonal Control of Lactation
Prolactin and oxytocin are necessary for establishing and maintaining a milk supply.
Prolactin : stimulates milk production, stimulates by suckling, stress, sleep, and sexual intercourse In the last 3 months
of pregnancy, prolactin activity is suppressed by a prolactin-inhibiting factor that is released by the hypothalamus
Hormonal control lactation cont..
Oxytocin : main role is in letdown, or the ejection of milk from the milk gland (acinus) into the milk ducts.
Stimulated by suckling or nipple stimulation
Oxytocin also acts on the uterus, causing it to contract, seal blood vessels, and shrink its size.

The Letdown Reflex

The letdown reflex : stimulates milk release from the breast
The stimuli -- through nerves to the hypothalamus -- promoting oxytocin release – oxytocin : contraction of the
myoepithelial cells -- milk is released through the ducts
Other stimuli : hearing a baby cry, sexual arousal, and thinking about nursing, can also cause letdown

Physiology of Lactation
Suckling stimulates nipple
--->pituitary gland secretes oxytocin--->let down reflex results in milk ejecting cells contract forcing milk from milk cells
into milk ducts.

Milk pools in lactiferous sinuses under the areola. Suckling stimulates milk to come from the nipple.

Lactation
Production and secretion of breast milk for purpose of nourishing infant
Supply and demand mechanism
No supplemental feedings should be given until feeding routine established
Human milk formulated to meet nutrient needs of infants for first six months of life

Calories – additional 1000 calories –help to produce milk

Protein – additional of 20 gms. , to compensate the protein lost in milk
Calcium & Phosphorous – Increase of 0.5 mg., to prevent severe depletion of maternal calcium for milk production
Iron – additional intake is recommended for blood lost
Vit. A – additional 2000 IU, needed in the ilk secretion
Riboflavin, Vit. C – increase

Fluids – 8 glasses or more

1)Diet – intake of meat & veg. soup (tahong, tulya, malunggay) “galactogue”
• Stimulate milk secretion
• Water should not be drunk beyond the level of natural thirst. It suppresses milk secretion
2. Nutritional State of Mother – Malnutrition and illnesses (cardiac and kidney diseases, anemia, beriberi, tuberculosis)
can lessen the quantity and quality of milk
• Emotional & Physical State – relax, pleasant surroundings, lots of rest and good sleep
• Suckling - suckling right after delivery stimulate milk secretion
• Contraceptives & Drugs – depress milk flow

Advantages of Breast Feeding

COLOSTRUM – thin yellowish fluid secreted during the first 2 days
1. Breast milk produces anti bodies, immunity against diseases
2.Lactose is higher in breast milk, to produce beneficial bacteria in the GI tract.
3.Calcium and Phosphorus level are regulated
4. Prevent dental arch
5.Cow’s milk protein causes allergy
6. Less incidence of lung cancer
7. Fast return of the uterus to its original size
8. Biologically complete
9. Easily digested
10. Convenient and dependable
 NCM 105: NUTRITION AND DIET THERAPY

11. Safe
12. Emotional satisfaction between mother & child

Benefits of Breastfeeding for the Infant

Breast milk has perfect composition for baby’s needs
No babies allergic to mother’s milk
Human milk contains at least 100 ingredients not found in formula
Breast milk provides antibodies
Benefits of Breastfeeding for the Infant
Lower incidence of ear infections, diarrhea, allergies, and hospital admissions
Promotion of good jaw development
Decreased risk of obesity later in life
Facilitation of bonding
Benefits of Breastfeeding for the Mother
Helps lose weight gained during pregnancy
Stimulates uterus to contract back to original size
Is economical
Provides opportunity for resting
Is always right temperature and readily available

B- est for baby, also best for mommy

R-educes the incidence of allergies
E-economical, no waste
A-nti-bodies to protect baby against infection
S-terile and pure
T-emperature is always ideal
F-resh milk never goes off
E-asy to prepare and to digest
E-radicates feeding difficulties
D-evelops mother and child bonding
I-mmediately available
N-utritionally optimal
G-astroenteritis greatly reduced

Tips of Breastfeeding:
1. With a clean washcloth or cotton swabs, wipe your breasts clean before your baby feeds.
2.Sit comfortably in an upright position.
3.Support your baby's head
4.Guide your nipple towards his mouth. Baby's chin should be against the breast and his tongue underneath your nipple.
Make sure that he's sucking the whole areola (darkened area of the nipple). 5.When he's sucking subsides, switch him to
other breast until stops feeding
6.Next time he feeds, start from the breast he nursed from last.
7.If your nipples get sore,never wash your nipples with soap, give a minute for them to be exposed for air dry
8.ALWAYS burp your baby after feeding.

Nutrient Requirements during Lactation

Food and Nutrition Board suggests increase of 500 calories per day
Most nutrient requirements increased
Especially protein
Base nutrition on MyPyramid
Fluid intake should replace fluids used for milk production
Most chemicals can pass into mother’s milk
Avoid alcohol, tobacco, and illegal drugs
Check with obstetrician before using any medication or nutrient supplement
Caffeine may make infant irritable

Considerations for the Health Care Professional

Articles in newspapers and magazines may be inaccurate
Re-education may be necessary
 NCM 105: NUTRITION AND DIET THERAPY

Teaching pregnant teenagers presents biggest challenge

Nutrition Problem in Breastfeeding Women

Weight Loss During Breastfeeding
Common Breastfeeding Conditions (ex: Hyperlactation, Plugged Duct, Mastitis, Engorgement) Low Vitamin and
Mineral Intakes → clinical manifestation based on those vitamin & mineral deficiency

Weight Loss During Breastfeeding

Current DRIs → assuming a weight loss of 0.8 kg/month
Postpartum weight changes are smaller in developing countries (–0.1 kg/mo) than in industrialized nations (–0.8 kg/mo)
Requirement of Energy, Vitamin, and Mineral → based on RDA / AKG for Lactation Women

Common Breastfeeding Conditions

Sore Nipples: proper positioning of the baby on the breast (nipple in junction of the hard and soft palate)
Flat or Inverted Nipples
Plugged Duct : pain
Mastitis : inflammation

Low Vitamin and Minerals Intake Intervention:

Optimal diet
Calcium, phosphate, folate, thiamin, vitamin A, vitamin D–rich foods such as: dairy products, fruit, vegetables, and whole-
grain
Requirement Vitamin and Mineral → based on RDA / AKG

Human Milk Composition

• colostrum, first milk, thick, often yellow fluid produced
• Infants may drink only 2 to 10 mL (1.5–2 tsp) of colostrum per feeding in the first 2–3 days.
• Colostrum higher in immunoglobulin A and lactoferrin (the primary proteins present in colostrum), mononuclear
cell, sodium, potassium, and chloride than more mature milk.

Immunological Contents of Breast Milk

Immunoglobulins
IgA, IgG, IgM, leukocytes, cytokines

Host resistance factors

Complement macrophages, lymphocytes, lactoferrin

Anti-inflammatory components
Enzymes: catalase, histaminase, lysozymes, lactoperoxidase

Antioxidants: acsorbic acid, alpha-tocopherol

Prostoglandins
Interleukin-6
Stimulates an increase in mononuclear cells in breast milk.
Breastfeeding
Advantages for Baby
Decreased incidence and/or severity of otitis media, diarrhea, lower respiratory infections, bacteremia, bacterial
meningitis, botulism, urinary tract infections, and necrotizing enterocolitis.
Less hospitalization in first 6 months.
Possible protective effect against sudden infant death syndrome, type 1 diabetes, Crohn’s disease, ulcerative colitis,
lymphoma, allergies, and chronic digestive diseases.

Composition of Breast Milk

Colostrum: small amount during days 3 to 5
High in protein, immunoglobulins and minerals,
Low in lactose and fat
Transitional milk: produced during days 6 to10
High in fat, lactose
 NCM 105: NUTRITION AND DIET THERAPY

Lower in protein and minerals

Mature milk: available by 2 weeks post-partum
Average secretion: 750 mg/d
Provides 20-22 kcal/ounce
60-80% whey protein, 40% lactose, 50% fat
Growth factor
Low in vitamin D
What is colostrum and how does the composition of milk change, both during a feed and as the baby grows?
✓ Colostrum is the first milk produced after the baby is born.
✓ It is of a different composition to the milk that follows and is particularly rich in protective factors and
growth factors.
✓ As well as changing in composition over time, breast milk also changes in composition during a feed.
✓ The milk available at the start of a feed is richer in nutrients and energy.

Nutrition and Lactation

Which aspects of diet are particularly important for women who are breast-feeding?
✓ It has been calculated that breast-feeding carries a daily energy cost of 650 kcal.
✓ However, some of this is obtained by using up fat stored during pregnancy for this purpose.
✓ Consequently, women who exclusively breast-feed for 3–4 months need an extra 500 kcal/day, on
average, which corresponds to an average milk output of 750 ml/day.
✓ Assuming that this extra energy is obtained via consumption of a balanced and varied diet, the additional
needs for essential vitamins and minerals will also be met. ✓ Additional requirements for calcium are
particularly high

Nutritional Requirements During Lactation

Breastfeeding is an anabolic state, resulting in increased energy and nutrient needs:
500 kcal/day (birth to 6 mo)
400 kcal/day (7 - 9 mo)
Protein, zinc, niacin, vitamins A, E, C requirements increase above those in pregnancy.
Protein = 71 g/day
Chronically low maternal iron, vitamin B, C, D, thiamin, and folate intake leads to low content in breast milk.
Should women who are breast-feeding avoid any particular foods?
✓ Some women report that, after they have consumed certain foods, e.g. spicy foods or onions, their babies
experience abdominal discomfort.
✓ If this occurs, such foods should perhaps be avoided, provided omission of the trigger foods does not
result in an unbalanced diet.
✓ Non-nutritive substances such as caffeine, nicotine and other amines and alkaloids can pass into breast
milk, and heavy consumption of coffee, tea and cola drinks has been reported to cause restlessness in
some infants.
✓ With regard o the prevention of allergy or other food intolerance in the baby, the benefits of mothers
avoiding specific foods during pregnancy and lactation are not proven.
✓ Furthermore, exposure via the mother may be an important factor in establishing a normal immune
response to proteins in the diet.
✓ Avoidance of foods associated with allergic reactions, e.g. milk, eggs or nuts, should be seriously
considered only when there is a strong family history of atopy.
Is fluid intake important?
✓ An adequate fluid intake is crucial postpartum for establishing breast-feeding and remains important
throughout, given that, by 2–3 months of age, a baby may be taking as much as 820 ml of milk a day.
✓ The best guide to requirement is thirst, and forced drinking of extra fluid will not increase milk quality or
quantity. Conclusion
✓ Pregnant woman most likely to remain healthy and bear healthy infant if following wellbalanced diet
✓ Anemia and pregnancy-induced hypertension
✓ Two conditions that can be caused by inadequate nutrition
✓ Caloric and most nutrient requirements increase for pregnant and lactating women

CHAPTER 3: INFANCY

Why is Nutrition Important?

 NCM 105: NUTRITION AND DIET THERAPY

Energy of daily living

Maintenance of all body functions
Vital to growth and development
Therapeutic benefits
Healing
Prevention
• Growth – increase in size due to increase in the number of cells •
Development – increase in functional ability

Behavioral Development of a Healthy Baby

0-1 month suckles & smiles
2-3 months vocalize & controls head
4-5 months controls hands & rolls over
6-7 months sits briefly & crawls
8-9 months grasps & pulls up
10-11 months walks with support
12 months stars to walk alone

Nutritional Requirements of the Infant

Birth weight doubles by 6 months and triples within first year Requirements:
Approximately 98 to 108 calories per kilogram of body weight each day
1.5 mL of water per calorie
Nutritional needs depend on child’s growth rate
Nutritional Requirements of the Infant Basis of diet:
Breast milk or formula
Vitamin K supplement routinely given at birth
Vitamin D supplement given in breastfed infants not exposed to sunlight
Excess vitamin A or vitamin D can be toxic
Fluoride may be supplemented as needed

Factors Influencing a Woman’s Choice to Breast-Feed or Bottle-Feed Culture

Age
Prior experience with, or exposure to, breast-feeding
Intent or need to return to work or school
Feeding the Newborn
What are the options?
Breast feeding
Colostrum: Transitions around days 3-5 and mature by day 10
Pediatricians recommends exclusive breast feeding for 6 months. Formula feeding
Newborns’ Nutritional Needs
Calorie requirements
105 to 108 kcal/kg/day
Fluid requirements
140 to 160 mL/kg/day Weight
Breast fed gain birth weight by 14 days
Gain 15 grams or 0.5 ounce per day
Formula fed gain birth weight by 10 days
Gain 30 grams or 1 ounce per day

Stages of Breast Milk

Colostrum
More protein, fat-soluble vitamins, and minerals
Immunoglobulins for passive immunity
Transitional milk
More fat, lactose, water-soluble vitamins, calories
Mature milk
Foremilk: high in water, vitamins, protein
Hindmilk: higher fat concentration
 NCM 105: NUTRITION AND DIET THERAPY

Composition of Breast Milk

Colostrum
Produced during the second trimester
A thick, yellowish-gold substance higher in antibodies and protein than breast milk, but lower in fat Foremilk
Very watery and thin, may have a bluish tint; what the infant first receives during the nursing session Hind
milk
Thicker and whiter with a higher quantity of fat and caloric content than foremilk
Feeding Schedule
Initial Feeding
Signs of feeding readiness
Assess suck/swallow/breathing pattern
Assess for gagging and respiratory distress
Colostrum is not irritating if aspirated
On demand schedule
Feeding cues
Breast feed 8-12 times per 24 hrs
Formula feed 6-8 times per 24 hrs

Breastfeeding Techniques
Physiology
Supply and demand
Oxytocin stimulates let-down reflex
Position baby
Baby’s body facing mom
Nose at breast with body in alignment
Latching on
Stimulate wide open mouth
Take in entire nipple with areola at gums
Prevent sore nipples
Feeding
Hear swallowing, see milk at mouth
Empty each breast
Break suction
Alternate breast and change baby’s position
Warm stored milk with warm water
Avoid supplemental feedings
Avoid pacifiers/different nipples
Elimination
6-8 wet diapers and several stools per day
Breast Milk
Recommended for first 6 to 12 months
Immunologic
Inhibit growth of bacteria and viruses
Decreases incidences of allergies
Nutritional
Facilitates digestion and absorption
Composition varies with gestational age
Iron better absorbed and adequate until 6 mos Lower renal solute
level
Psychosocial
Maternal/infant bonding
Less expensive than formula
Pumping when mother is not available

Breast Feeding
Advantages to Infants
It's usually more easily digested than formula. So breastfed babies are often less constipated and gassy.
It may raise your child's intelligence. Studies show breastfed babies have higher levels of cognitive function.
Decreased incidence of ear infections, otitis media, UTI, gastroenteritis, diarrhea, and lower respiratory tract infections /
 NCM 105: NUTRITION AND DIET THERAPY

respiratory illnesses, and bacteremia.

Convenient and ready to eat.
Fosters unique experience for mother-infant bonding.

Advantages of Breast-Feeding
Infant benefits
Provides immunologic properties from the woman
Decreases the risk in overfeeding of the newborn
Possibly protects against certain conditions or diseases such as SIDS, insulin-dependent diabetes, and allergic
diseases
Breastfeeding
Infants obtain temporary immunity to many infectious diseases Have fewer
infections
Has benefit of being the following:
Economical
Nutritionally perfect
Sterile
Easily digested

Promotes oral motor development

Offer breast every two hours in first few weeks
Have infant nurse 10 to 15 minutes on each breast
Growth spurts occur at approximately 10 days, two weeks, six weeks, and three months
Infant may nurse more frequently

Breast Feeding
Advantages to Mothers
May delay return of ovulation.
Cost effective
Suppresses post-partum bleeding.
Reduced risk of breast cancer, diabetes, heart disease, osteoporosis, and ovarian cancer.
More rapid uterine involution
Less bleeding in the postpartum period
A quicker return to pre-pregnancy weight level

Indications of adequate nutrition include:

Infant has six or more wet diapers per day
Infant has normal growth
Infant has one to two bowel movements per day
Breast becomes less full during nursing

Contraindications to Breast-Feeding
Illegal drug use
Active untreated TB
HIV infection
Chemotherapy treatment
Herpetic lesions on the breast
Insufficient production of breast milk
Galactosemia or phenylketonuria in the infant

Newborn Features Facilitating Breast-Feeding

Uniquely shaped nose and mouth
The rooting reflex
Innate ability to suck

Factors Controlling Lactation

Physical control of lactation
Hormonal control of lactation
Sensory stimulation
 NCM 105: NUTRITION AND DIET THERAPY

Assessment of Breast Feeding

Weight pattern - consistent weight gain.
Stooling - generally more stools than formula.
Feed-on-demand ~ every 2-3 hours.
Duration of feedings - generally 10-20 min/side.
Primary source of nutrition first 6 months

Nursing Care for the Breast-Feeding Woman

Assessing breast-feeding readiness
Assisting with breast-feeding technique
Assessing the breast-feeding session
Ending the breast-feeding session
Assessing newborn fluid intake
Teaching about breast-feeding special concerns
Relieving common maternal breast-feeding problems

Positions for Breast-Feeding

Cradle hold
The newborn’s abdomen is facing and touching the woman’s abdomen
Football hold
The newborn is held with its head under the woman’s breast
Side-lying position
Both the woman and the newborn are on their sides facing each other while lying in bed

Common Maternal Breast-Feeding Problems

Sore nipples
Engorgement
Plugged milk ducts
Mastitis

Teaching Topics for the Breast-Feeding Woman

Signs newborn is not feeding well
Growth spurts
Available resources
Using supplements
Breast-feeding amenorrhea
Contraception while breast-feeding
Pumping and storing breast milk

Storing Breast Milk

Store in hard plastic container with a label stating time and date.
Store at 4˚C/40˚F or below and transport on ice
Do not leave at room temperature and do not reuse
Storage concerns: Room air, 6 hrs; refrigerator, 24 hrs; freezer, 6 mos

Signs a Newborn Is Not Feeding Well

Dry mouth
Not enough wet diapers per day
Difficulty rousing the newborn for a feeding
Not enough feedings per day
Difficulty with latching and/or sucking

Bottle Feeding
Synthetic formula made from soybeans may be used for infants who are sensitive or allergic
Formula must be prepared with correct amount of water to prevent health complications
Infant should be cuddled and held in semi-upright position
Infant should be burped often
Formulas made from modified cow’s milk to resemble breast milk in nutritional value Cow’s milk
 NCM 105: NUTRITION AND DIET THERAPY

can cause gastrointestinal blood loss in infants Avoid use

Use consistent temperature for formula
Putting infants to bed with bottle may cause baby bottle mouth

Advantages of Formula Feeding

Feeding infants who are adopted
Feeding infants in cases where breast-feeding would be harmful
Quantifying the amount of formula consumed
Perceived ease of formula feeding vs. breast-feeding
Involvement of others in feeding infant

Disadvantages of Formula Feeding

It is inferior nutrition
It has no immunologic properties
It is harder for the newborn to digest
There is a higher correlation between infants who are formula fed and some illnesses like otitis media and allergies It is
expensive Formula
st

No cow’s milk until after 1 year

Types
Cow’s milk protein or soy-protein
20 kcal/oz (24 kcal/oz)
Preparation
Ready to feed, liquid concentrate, powder
Dilution
Storage

3 Main Types of Formula

Milk-based
Soy-based
Hypoallergenic

Nursing Care of the Formula-Feeding Woman

Assisting with formula-feeding technique
Assessing the formula-feeding woman and newborn
Teaching about formula-feeding concerns
Preparing bottles of formula
Adding supplements
Maternal breast care
Common problems in the formula-fed newborn

Common Problems in the Formula-Fed Newborn

Not wanting to eat
Not tolerating the formula
Dental caries
Infant Formula 3
Forms:
Ready to feed - most expensive, does not require water.
Concentrate - requires mixing with water in equal parts. Powder - requires
mixing with water.

Composition of Standard
Infant Formula
Caloric density: standard formulas contain 20
calories/oz (0.67 calories/cc).
Protein content: ratio of whey to casein varies- most are 60:40
similar to human milk.
Fat: most provide ~50% of calories from fat from saturated and polyunsaturated fatty acids.
Carbohydrate: lactose, beneficial effect on mineral absorption (Ca, Zn, Mg), and on colonic flora. Micronutrients: Higher
 NCM 105: NUTRITION AND DIET THERAPY

vitamin and mineral content than human milk

Special Formulas
Soy: used for vegetarians, lactase deficiency, galactosemia.
Lactose free: cow’s milk-based formula.
Protein hydrolysate: infants who can not digest or are allergic to intact protein.
Free amino acids.
Pre-term infant: unique for premies, predominant whey protein, cow’s milk based, higher protein and calcium, 20-50%
MCT.
Pre-term follow up

Bottle feeding
Hold baby for all feedings Head
elevated
Formula/milk in nipple
Newborn: 1-3 oz every 3-4 hrs
Birth to 2 mos: 2-4 oz at 6-8 a day
Bottle feeding

Preparation and storage

Clean bottles and water
Fresh bottle for each feeding
Use within 1 hour if not refrigerated
Prepare enough for only 24 hours

Do’s and Don’ts

Need soft and squeeze easy
Check condition of nipple, should drip out steadily
Nipple should be kept full of milk to avoid excessive air swallowing
Never prop bottle - choke more often when bottles are propped. They also fall asleep with milk in their mouth, promoting
gum disease and tooth decay. Milk runs down the face and into the ears, causing more ear infections
Never put baby to bed with bottle- can cause tooth decay

Feeding Skills Development

4-6 mos - experience new tastes.
Give rice cereal with iron.
6-7 mos - sits with minimal support.
Add fruits and vegetables.
8-9 mos - improved pincer grasp.
Add protein foods and finger foods.
10-12 mos - pulls to stand, reaches for food.
Add soft table food, allow to self-feed.
12-18 mos - increased independence.
Stop bottle, practice eating from a spoon.
18 mos -2 yrs - growth slows, less interest in eating.
Encourage self-feeding with utensils.
2-3 yrs - intake varies, exerts control.

Feeding Skills at 4 – 6 Months

• Baby will feed in semi-reclined position
• Visually recognizes bottle
• Continues to bring hands and toys/objects to mouth
• Uses hands to pat bottle/breast during feeding
• Begins to eat puree/smooth creamy foods by sucking food from a spoon
• Child should demonstrate a good coordination of suck and swallow
• By 6 months, child will swallow strained foods
• Recognizes the bottle or breast
Feeding Skills at 6 – 8 Months
 NCM 105: NUTRITION AND DIET THERAPY

• Eating in more upright positions

• Tongue can lateralize/move toward cheeks
• Mouthing and munching spoon, toys and biter biscuits
• Holds own bottle
• Drinking from a cup held for child
• Eating mashed, soft table foods (potatoes, carrots, fruits, etc.) with creamy, lumpy texture
• Drooling less except for teething
• Bite and release observed
• Moves food around in mouth using tongue, bites and chews toys
Feeding Skills at 8 – 12 Months
• Sitting upright during meals
• Biting and chewing foods voluntarily
• Eating finger foods with pureed meats
• Meats should stay one consistency below vegetables and fruit child is eating
• Controlled sustained bite
• Developing a rotary chew pattern
• Finger feeds self
• Holds spoon during meals
• Moves food around in mouth using tongue, bites and chews toys
• Finger feeds self, chews food
Feeding Skills at 12 – 18 Months
• Eating table foods, but meat chopped/cut up very small
• Lips closed during chewing
• Appetite decreases during this time resulting in food refusal occasionally
• Brings a spoon to mouth and turns spoon over
• Holds and drinks from a cup with some spills
• Appetite decreases, may refuse food
• Scoops food with spoon, brings food to mouth
Feeding Skills at 18 – 24 Months
• Chewing with rotary jaw movements
• Distinguishes between food and non-food items
• Gives up bottle
• Gives empty bowl or dish to an adult
• Scooping foods to feed self, with some spills
• Plays/explores foods with hands
• Holds small cups with one hand
• Plays with food
• Knows the difference between food and non-food items
• Transitions to a cup
• Develops clear food preferences
Feeding Skills at 24 – 30 Months
• Holds spoon between fingers, palm up
• May have definite food likes and dislikes
• Often the time ‘picky eater’ shows up
• Unwraps food
• Holds spoon
• Washes hands
• May show dislike and refuse certain foods
Feeding Skills at 30 – 36 Months
• Uses a fork to feed self
• Wipes mouth with napkin
• May reject many foods due to slower rate of growth and more mature sense of taste
• Attempts to serve self at table with spills
• Pours liquids from small containers
NCM 105: NUTRITION AND DIET THERAPY
 NCM 105: NUTRITION AND DIET THERAPY

Desired Outcomes for the Infant and the Role of the Family in the Feeding Relationship
 NCM 105: NUTRITION AND DIET THERAPY

Supplementary Foods
Wait until 4 to 6 months before introducing solid foods
Do so gradually
Solids should be started with iron-fortified rice cereal
Then other infant cereals
Follow with cooked and pureed vegetables, then cooked and pureed fruits, egg yolk, and finely ground meats
Between 6 and 12 months, add toast, Zwieback teething biscuits, and Cheerios
Supplementary Foods
Never give honey to infant
Could be contaminated with Clostridium botulinum bacteria
Can introduce juice when drinking from cup
Never give from bottle
Will fill up on juice and not get enough calories from other sources
Use only 100 percent juice products
Limit to 4 ounces per day
Nutrient-dense
Indications for Readiness for Solid Foods
Disappearance of extrusion reflex
Pushing food out with tongue
Willingness to participate
Ability to sit up without support
Control of head and neck
Drinking of more than 32 ounces of formula or nursing eight to 10 times in 24 hours
 NCM 105: NUTRITION AND DIET THERAPY

Developing Good Eating Habits

By age 1, most babies can eat foods from all food groups
Can use table foods
Avoid excess sugar and salt
Avoid foods that can cause choking
Help children develop active lifestyle and healthy eating habits

Special Nutritional Needs

Premature infants
Cystic fibrosis
Failure to thrive
Metabolic disorders:
Galactosemia
Phenylketonuria (PKU)
Maple syrup urine disease (MSUD)

Premature Infants
Infant born before 37 weeks of gestation
Sucking reflex not developed until 34 weeks of gestation
Infants born earlier require total parenteral nutrition, tube feedings, or bolus feedings Other concerns:
Low birth weight, underdeveloped lungs, immature gastrointestinal tract, inadequate bone mineralization, and
lack of fat reserves
Many special formulas available, but breast milk best
Composition perfect even for premature infants

Cystic Fibrosis
Inherited disease in which body secretes abnormally thick mucus Decreased production of
digestive enzymes and malabsorption of fat Recommendation:
35 to 40 percent of diet should be from fat
Digestive enzymes and fat-soluble vitamin supplementation at meal times
Nighttime tube feedings may be indicated
Failure to Thrive
Determined by plotting infant’s growth on standardized charts
May be caused by watering down formula, congenital abnormalities, acquired immunodeficiency syndrome (AIDS), lack
of bonding, child abuse, or neglect
Failure to Thrive
First six months most crucial for brain development

Galactosemia
Caused by lack of transferase
Converts galactose to glucose
Amount of galactose in blood becomes toxic
Results in diarrhea, vomiting, edema, and abnormal liver function
Cataracts may develop
Galactosuria and mental retardation occur
Galactosemia Diet
therapy:
Exclusion of anything containing milk from any mammal
Nutritional supplements of calcium, vitamin D, and riboflavin Lifelong
elimination or restriction of lactose in diet may be needed

PKU (Phenylketonuria)
Infants lack liver enzyme phenylalanine hydroxylase
Necessary for metabolism of amino acid phenylalanine
Infants normal at birth, but if untreated, become hyperactive, suffer seizures, and become mentally retarded between 6
and 18 months Lifelong diet therapy:
Commercial formula Lofenalac
Regular blood tests
 NCM 105: NUTRITION AND DIET THERAPY

Synthetic milk for older children

Avoidance of phenylalanine
Hospitals required to screen newborns before discharge

MSUD (Maple syrup urine disease)

Congenital defect resulting in inability to metabolize three amino acids: Leucine,
isoleucine, and valine Named for odor of client’s urine
Ketosis occurs with protein ingestion
Hypoglycemia, apathy, and convulsions occur
If not treated promptly, may result in death Lifelong diet
therapy:
Extremely restricted amounts of the three amino acids
Special formula and low-protein diet

Spotlight on the Life Cycle

Women, Infants, and Children (WIC)
Federally funded program that provides monthly food packages of infant formula or milk, cereal, eggs, cheese,
peanut butter, and juice to new mothers

Methods of Feeding the Infant:

1) Breast Feeding
2) Artificial Feeding – bottle feeding using infant formula 3)Mixed Feeding – combination of
breast & bottle Milk Formula:
A) Whole Cows Milk Formula
1. Powdered whole cow’s milk – milk dried under controlled condition (Nido, Birch Tree, Anchor Mik)
2. Full Cream evaporated Milk – whole milk from which 50-60% of water content has been removed 3. Recombined
milk – skim milk powder reconstituted to normal fat content of the whole milk by adding butterfat
4.Reconstituted milk – process milk to which water is added to restore its original water content
(Frisian Girl, Alpine)

B) Other type of evaporated milk not recommended for infants

1. Sweetened condensed – High in sugar resulting in very diluted milk formula
2. Evaporated Filled Milk – cow’s milk from which butterfat has been removed and replaced with vegetable oil (94%
coconut oil, 6% corn oil)
3. Skim Milk – butter fat has been removed (Enfamil, Olac)
4.Acidified Milk – increase digestibility ( Pelargon, Acidolac)
5.Completely Modified Milk Formula – Protein & mineral content are adjusted to resemble human milk (SMA, S-26,
Similac)
6. Non- cows Milk formula – Soybase for infant’s allergy to cow’s milk ( Sobee, Mullsoy, Isomil)

Note: goat’s milk has also been found effective as hypoallergenic milk

Baby’s Food During the 1st Year of Life:

1. Cereal Foods – (3-4 months), milk is still continued
2. Fruits – (3-4 months) , mashed
3. Vegetables – (3-4 months) , mashed (carrots, squash, sayote,) green leafy vegetables may be mashed and sieved and
mix with other foods.
4. Eggs –( 4- 5 months) , only eggyolk is given
5. (9-10 months) , can give the whole egg
6. Munggo – ( 5 months) cooked well and strained
7. Meat, fish or Poultry – ( 5-6 months) , ground and strained
8. Other Foods – custards, puddings, plain ice cream, plain gulaman or jello

HOW TO GIVE SUPPLEMENTARY FOODS

• Introduce one food at a time
• Give small amounts of foods
• Use thin, soft consistency. Gradually, modify the consistency
• Never force an infant to eat more of a food he can takes
• Omit the food if the infant refuse to eat several times
 NCM 105: NUTRITION AND DIET THERAPY

• slightly seasoned with small amt. of salt

• Variety of foods is important
• don’t show any dislikes for the food

Conclusion
Infants must have adequate diets to avoid impairment of physical and mental development Breastfeeding
Nature’s way of feeding infant
Formula feeding also acceptable
Some infants have special nutritional needs