NUTRITION IN PREGNANCY AND BREASTFEEDING

OVERVIEW
Nutrition is a key factor of prenatal care for all women. Nutrition requirements
increases tremendously during pregnancy and lactation as the expectant or
nursing mother not only has to nourish herself but also the growing fetus and the
infant who is being breastfed (Michelle A. et al. 2016).
Pregnancy and breastfeeding are the most nutritionally demanding times of a
woman’s life. The body needs enough nutrients every day to maintain its needs
and also to support the growth of a baby.
All the nourishment the developing baby needs comes from the mom, either
through the foods she eats adequate diet which include whole grains, legumes,
lean meat, milk and milk products, fruits and vegetables) or the supplements she
takes.
DEFINITION OT TERMS
Nutrition is the science that interprets the nutrients and other substance in food
in relation to maintenance, growth, reproduction, health and disease of an
individual. It includes ingestion, absorption, assimilation, biosynthesis, catabolism
and excretion.
Pregnancy occurs when a sperm fertilizes an egg after it’s released from the ovary
during ovulation. The fertilized egg then travels down into the uterus where
implantation occurs. A successful implantation results in pregnancy.
Breastfeeding, also called nursing, is the process of feeding a mother’s breast milk
to her infant, usually directly from the breast for nourishment.

PREGNANCY
Pregnancy is a period of great physiological stress for a woman, as she nurtures a
growing fetus in her body. On average, a full term pregnancy lasts about 40
weeks. Infants delivered before the end of 37 weeks are considered pre-mature,
while full term babies are born as early as 37 weeks and as late as 42 weeks. The
weeks are grouped into three trimesters.
First Trimester

o This is a period from 1 - 12 weeks and it is the most crucial to the fetus
development.
o In this period, the fetus body structure and organs, systems develop.
o At about 8 weeks the fetus heart begins to beats
o Most miscarriages and birth defects occur during this period
o The body undergoes major changes such as nausea, fatigue, breast
tenderness, food aversions etc.

Second Trimester

o This period is from 13 - 28weeks

o This is often called the “golden period” because many of the unpleasant
effects of early pregnancy disappear.
o There is a better sleep pattern and increased energy level, the fetus
muscles and bones continues to form. The fetus is more active (between 16
& 20weeks), it can suck, kick or punch.
o The sex of the fetus can be known using ultrasound.
o The abdomen expands as the fetus grow and new symptoms such as back
pain, abdominal pain, leg cramp, constipation etc. sets in.
o Darkening of the skin around the nipples

Third Trimester

o It is a period of 29 - 40 weeks.
o The fetus bones are fully formed but still soft, body fat increases as fetus
grows bigger.
o A full term baby falls within the range of 2.5 - 4.5kg body weight.
o The mother experiences shortness of breath, hemorrhoids, urinary
incontinence, varicose vein and sleeping problems, due to increase in size
of the uterus.
o As the due date draws closer, the cervix becomes thinner and softer, this is
called effacing.

SIGNS AND SYMPTOMS OF PREGNANCY

o Missed period
 o Tender, swollen breast
o Nausea with or without vomiting
o Fatigue
o Moodiness/ mood swing
o Light spotting
o Cramping
o Bloating

PHYSIOLOGICAL CHANGES
Physiological changes occur in pregnancy to nurture the developing foetus and
prepare the mother for labour and delivery. Some of these changes influence
normal biochemical values while others may mimic symptoms of medical disease.
Below are some physiological changes:
o Plasma volume increases progressively throughout normal pregnancy. Most
of this 50% increase occurs by 34 weeks gestation and is proportional to the
birth weight of the baby. Dilutional anaemia is caused by the rise in plasma
volume. Elevated erythropoietin levels increase the total red cell mass by
the end of the second trimester but haemoglobin concentrations never
reach pre-pregnancy levels.
o Pregnancy causes a two- to three-fold increase in the requirement for iron,
not only for haemoglobin synthesis but also for the foetus and the
production of certain enzymes. There is a 10- to 20-fold increase in folate
requirements and a two-fold increase in the requirement for vitamin B12.
o Cardiac output increases by 20% by week 8, and then further up to 40%
increase, maximal at week 20-28. In labour there is further increase in
cardiac output and then a huge increase immediately after delivery,
followed by return to normal within around an hour. There is an increased
risk of pulmonary oedema if there is an increase in blood volume, or
increased pulmonary capillary permeability secondary to pre-eclampsia.
The highest risk time is the second stage of labour or immediate
postpartum period when cardiac output is high.
o The increase in estrogen during pregnancy enables the uterus and placenta
to: improve vascularization (the formation of blood vessels), transfer
nutrients and support the developing baby. Estrogen levels increase
steadily during pregnancy and reach their peak in the third trimester. The
rapid increase in estrogen levels during the first trimester may cause some
 of the nausea associated with pregnancy. During the second trimester, it
plays a major role in the milk duct development that enlarges the breasts.
o Progesterone levels also are extraordinarily high during pregnancy. High
levels of progesterone cause internal structures to increase in size, such as
the ureters. The ureters connect the kidneys with the maternal bladder.
Progesterone is also important for transforming the uterus from the size of
a small pear in its non-pregnant state to a uterus that can accommodate a
full-term baby.
o Progesterone causes relaxation of the lower oesophageal sphincter and
increased reflux, making many women prone to heartburn. Pressure on the
stomach from the enlarging uterus further contributes to this in later
pregnancy.
o Gastrointestinal motility is reduced and transit time is consequently longer.
This allows increased nutrient absorption. Constipation is common.
o The gallbladder may dilate and empty less completely. Pregnancy also
predisposes to the precipitation of cholesterol gallstones.
o The increased blood volume and cardiac output during pregnancy cause a
50-60% increase in renal blood flow and glomerular filtration rate (GFR).
This causes an increased excretion and reduced blood levels of urea,
creatinine, urate and bicarbonate.
o Mild glycosuria and/or proteinuria may occur because the increase in GFR
may exceed the ability of the renal tubules to reabsorb glucose and protein.
o Pregnancy is associated with a relative iodine deficiency. The causes for this
are active transport of iodine from the mother to the foeto-placental unit
and increased iodine excretion in the urine.
o Although fetal need for calcium is high, maternal serum calcium levels are
maintained in pregnancy by increased intestinal absorption. There is also
increased excretion in the urine, as a result of which pregnant women are
at increased risk of renal stones.
o Cholecalciferol (vitamin D3) is converted to its active metabolite, 1, 25-
dihydroxycolecalciferol, by placental 1α-hydroxylase. Serum levels rise and
are responsible for the increased intestinal absorption of calcium.

METABOLIC CHANGES IN PREGNANCY

Maternal metabolism changes substantially during pregnancy. Early gestation can
be viewed as an anabolic state in the body with an increase in maternal fat stores
and small increases in insulin sensitivity. Hence, nutrients are stored in early
pregnancy to meet the feto-placental and maternal demands of late gestation
and lactation. In contrast, late pregnancy is better characterized as a catabolic
state with decreased insulin sensitivity increased insulin resistance). An increase
in insulin resistance results in increase in maternal glucose and free fatty acid
concentrations, allowing for greater substrate availability for fetal growth.
Metabolic changes during pregnancy are among the many adjustments that the
mother’s organs make to meet the requirements created by the increase in her
own breast and genital tissues and the growth of the conceptus the fetus and
afterbirth).
Basal Metabolic Rate
o The amount of oxygen consumed is an index of the pregnant woman’s
metabolism when she is at rest.
o The rate begins to rise during the third month of pregnancy and may
double the normal rate +10%) by the time of delivery.
o The rate rises in specific proportion to the size of the fetus and represents
the effects of the mother’s activities plus those of the fetus and the uterine
structures
o An elevation of the basal metabolic rate (BMR) to 20 or 25 percent during
pregnancy is not an indication of an overly active thyroid gland.

Carbohydrate Metabolism
o Pregnancy is a diabetogenic state and the adaptations in glucose
metabolism allow shunting of glucose to the foetus to promote
development, while maintaining adequate maternal nutrition. Insulin-
secreting pancreatic beta-cells undergo hyperplasia, resulting in increased
insulin secretion and increased insulin sensitivity in early pregnancy,
followed by progressive insulin resistance.
o Maternal insulin resistance begins in the second trimester and peaks in the
third trimester. This is the result of increasing secretion of diabetogenic
hormones such as human placental lactogen, growth hormone,
progesterone, cortisol and prolactin. These hormones cause a decrease in
insulin sensitivity in the peripheral tissues such as adipocytes and skeletal
muscle by interfering with insulin receptor signalling. The effect of the
 placental hormones on insulin sensitivity is made evident postpartum when
there is a sudden decrease in insulin resistance.
o Insulin levels are increased in both the fasting and postprandial states in
pregnancy. Fasting glucose levels are however decreased due to: increased
storage of tissue glycogen, increased peripheral glucose use, decrease in
glucose production by the liver and uptake of glucose by the foetus.
o Insulin resistance and relative hypoglycemia results in lipolysis, allowing the
pregnant mother to preferentially use fat for fuel, preserving the available
glucose and amino acids for the foetus and minimizing protein catabolism.
o The placenta allows transfer of glucose, amino acids and ketones to the
foetus but is impermeable to large lipids. If a woman’s endocrine
pancreatic function is impaired, and she is unable to overcome the insulin
resistance associated with pregnancy then gestational diabetes develops.

Protein Metabolism
o Pregnant women require an increased intake of protein during pregnancy.
Amino acids are actively transported across the placenta to fulfill the needs
of the developing foetus. During pregnancy, protein catabolism is
decreased as fat stores are used to provide for energy metabolism.
o During pregnancy, nitrogen, derived from the metabolism of
ingested protein, is needed for growth of the fetus, the placenta, the
uterus, and the mother’s breasts and other tissues. A considerable amount
of nitrogen also is required for the increase in the mother’s red cell volume
and blood plasma. 
o The fetus’s demand for nitrogen is slight at first, but during the last month
of pregnancy it acquires almost half of its total protein.
o In the process of accumulating this store and of building a reserve for the
period after delivery, the woman who is on an adequate diet retains
between two and three grams of nitrogen daily during her pregnancy; by
term her and the fetus will have acquired approximately 500 grams (about
1.1 pounds) of nitrogen.

Fat Metabolism
o There is an increase in total serum cholesterol and triglyceride levels in
pregnancy. The increase in triglyceride levels is mainly as a result of
 increased synthesis by the liver and decreased lipoprotein lipase activity,
resulting in decreased catabolism of adipose tissue.
o Low-density lipoprotein (LDL) cholesterol levels also increase and reach
50% at term. High-density lipoprotein levels increase in the first half of
pregnancy and fall in the third trimester but concentrations are 15% higher
than non-pregnant levels.
o Changes in lipid metabolism accommodate the needs of the developing
foetus. Increased triglyceride levels provide for the mother’s energy needs
while glucose is spared for the foetus. The increase in LDL cholesterol is
important for placental steroidogenesis.

WEIGHT
o The early part of pregnancy usually is accompanied by moderate weight
loss caused by the woman’s lack of appetite and in some cases nausea and
vomiting.
o Between the third and the ninth month of pregnancy most women gain
about 9 kilograms (20 pounds) or more.
o Ideally, during pregnancy, body weight is gained at the rate of about 0.5
kilogram (1 pound) per week. WHO found out that a total gestational
weight pain of 10 to 14 kilograms (22 to 30 pounds) was associated with
optimal infant birth weights.
o In an average pregnancy the infant, the afterbirth, and the fluid in the
uterus weigh about 4.5 kilograms (10 pounds).
o Excessive weight gain may be the result of over-eating, it may be caused by
a disturbance in metabolism and by an abnormal retention of fluids and
salts.
o In the latter instance, it may be the first sign of pre-eclampsia.
o An increase of 20 or more pounds above recommended weight gain based
on pre-pregnancy body mass index is associated with a significant increase
in the risk of complications at the time of delivery, including eclampsia,
maternal heart failure, and maternal need for ventilation.
GESTATIONAL WEIGHT GAIN TABLE
Pre Pregnancy BMI Total Weight Gain at Rate of Weight in 2nd
Term and 3rd Trimester (Mean
Range)
Underweight < 12.5 – 18kg 0.51 (0.44 -0.58)kg/week
2 28 – 40lbs. 1 (1- 1.3) lbs./week
18.5Kg/m )
Normal weight 18.5 – 11.5 -16kg 0.42 (0.35 -0.50)
2 25 – 35lbs. kg/week
24.9Kg/m )
1 (0.8 -1) lbs./week
Overweight 25.0 – 7 -11.5kg 0.28 (0.23 – 0.33)
2 15-25lbs. kg/week
29.9Kg/m )
0.6 (0.5 – 0.7) lbs./week
2 5 – 9kg 0.22 (0.17 –
Obesity ≥ 30.0Kg/m )
11-20lbs. 0.27)kg/week
0.5 (0.4 - 0.6) lbs./week
Data from Institute of Medicine. Weight gain during pregnancy: reexamining the
guidelines. Washington, DC: Institute of Medicine: 2009

HIGH RISK PREGNANCY

A pregnancy is considered high-risk when there are potential complications that
could affect the mother, the baby or both.
Risk factors for high-risk pregnancy are:
o Maternal age: Women below the age of 17 and above 35 years.
o Pre-existing medical conditions such as high blood pressure, diabetes, lung,
kidney or heart problems, HIV etc.
o Medical conditions that occur during pregnancy such as pre-eclampsia,
gestational diabetes, preterm birth, anemia, hyperemesis gravidarum etc.
o Pregnancy-related issues like, premature labor, multiple birth, placenta
Previa.
o Fetal problems like Down syndrome, spina bifida, heart defect etc.
 o Pregnant women who are drug & alcohol abusers, anorexic or bulimic and
also smokers

IMPORTANCE OF GOOD NUTRITION IN PREGNANCY

o A healthy and adequate diet during pregnancy plays the most important
role for both the unborn baby and the mother. It is important, since it
directly affects the weight of the baby at the time of birth.
o It also helps good fetal brain development and reduces the risk of many
birth defects. 
o An adequate diet will reduce the risk of anemia, as well as other unpleasant
pregnancy symptoms such as fatigue and morning sickness.
o Women with poor diets before pregnancy are more likely to give birth
prematurely than women who have healthy diets. Therefore, it is always
recommended to maintain a healthy diet, remain active, and drink lots of
fluids.
o Poor diet during pregnancy affects mother’s health, a malnourished mother
provides nutrients to the fetus at the expense of her own tissues. This
increases the risk of complications such as prolonged labor and even death

NUTRITIONAL REQUIREMENTS IN PREGNANCY

 Calorie/Energy Requirement
o In the first trimester, energy requirement is the same as non-pregnant
women and then increase in the second trimester, estimated at 300kcal
and 500kcal per day in the third trimester (Food and Nutrition board,
Institute of Medicine, 2002).
o Calorie needs depends on a women’s age, BMI before pregnancy and
activity level.
 Carbohydrate
o Carbohydrates should comprise 45-65% of daily calories and this includes
approximately 6-9 servings of whole grain daily (Food and Nutrition board,
Institute of Medicine, 2002).
 Protein
o Recommended protein intake during pregnancy is 60g/day, which
represents an increase from 46g/d in non-pregnant states. In other words,
this increase reflects a change to 1.1g of protein/kg/day during pregnancy
 from 0.8g of protein/kg/day for non-pregnant states (Food and Nutrition
board, Institute of Medicine, 2002).

 Fat
o Total fat intake should comprise 20-35% of daily calories, similar to non-
pregnant women (Food and Nutrition board, Institute of Medicine, 2002).
o Fat containing polyunsaturated and monounsaturated fatty acids should be
consumed since they contain omega 3 and 6 fatty acids important in fetal
brain development, also serves as energy supply to the woman.
o Micronutrients of key importance are folate, iron, calcium, vitamin D,
iodine, vitamin A
 Folate
o Folate is a B vitamin is necessary to support cell growth, cell replication, cell
division and nucleotide synthesis for fetal and placental development
(Michelle A. et al, 2016).
o About 400 to 800 micrograms a day of folate or folic acid before conception
and throughout pregnancy.
o Deficiency; neural tube defects of which spina bifida and anencephaly is
most common, preterm birth or stillbirth.
o Sources include; fortified cereals, leafy green vegetables, citrus fruits, and
dried beans and peas are good sources of naturally occurring folate.
o Folic acid supplementation has been shown to decrease the risk of
premature birth and neural tube defects.
 Iron
o Iron requirement is 27 milligram per day. In combination with Sodium,
Potassium, and Water, Iron helps increase blood volume and prevents
anemia.
o Deficiency causes iron deficiency anaemia, low birth weight, preterm labor,
post-partum hemorrhage and also increased cardiovascular risk for the
baby.
o Sources include green leafy vegetables, organ meats, meat, beans etc.

 Vitamin C
o This promotes wound healing, tooth and bone development, and metabolic
processes.
 o Helps in absorption of non-heme iron (i.e. iron from plant sources)
o Experts recommend at least 85 milligrams per day.
o Sources are; citrus, spinach, guava, cabbage, sweet potatoes etc.

 Calcium
o The daily requirement of Calcium is around 1000 milligrams during
pregnancy and about 1300 milligram in teenage pregnancy (IOM, 2009).
o In pregnancy there is an increased intestinal absorption and increased renal
retention.
o Adequate calcium intake is associated with high birth weight, reduced risk
of preterm delivery and better blood pressure control.
o WHO recommends 1.5-2.0g/day from the 20th week especially for women
at risk of gestational hypertension.
o Calcium helps your body regulate fluids, and it helps build your
baby’s bones and tooth buds.
o Sources include milk and milk products, fishes or sea foods, spinach etc.
 Vitamin D
o Is a fat soluble vitamin that promotes the absorption of calcium from the
intestines, thereby allowing appropriate bone mineralization and growth.
o Cholecalciferol (vit.D3 derived from cholesterol) is synthesized in the body
when exposed to sunlight and ergocalciferol (vit.D2) is gotten from food
sources.
o Deficiency causes congenital rickets and fractures.
o Vitamin D requirement is 60 international units (IU) a day.
o Sources include; egg, fish, milk, butter etc.

 Iodine
o Iodine is a major component of thyroid hormones and is required for
growth, formation and development of the organs and tissues.

FOOD SAMPLES AND NUTRIENT CONTENTS

Nutrients Food sources Serving size Nutrient quantity
Folate Black eyed beans ½ cup 105µg
 Spinach ½ cup 130µg
Banana 1 medium size 44µg
Avocado pear ½ cup 59µg
Iron Meat 85g 3mg
Fortified cereals ½ cup 20mg
Kidney beans ½ cup 2mg
Calcium Skim milk 1 cup 299mg
Yogurt 1 cup 379mg
Salmon 2 servings(90g) 181mg
Spinach ½ cup 161mg
Vitamin D Fish 2 servings(90g) 570IU
Milk 1 cup 115IU
Hard-boiled egg 1 serving(50g) 44IU

Recommended Daily Dietary Allowance for Pregnant women

Nutrients Non- pregnant Pregnant
Vitamin A (μg/d) 700 770
Vitamin D (μg/d) 5 15
Vitamin E (mg/d) 15 15
Vitamin K (μg/d) 90 90
Folate (μg/d) 400 600-800
Niacin (mg/d) 14 18
Riboflavin (mg/d) 1.1 1.4
Thiamin (mg/d) 1.1 1.4
Vitamin B (mg/d) 1.3 1.9
6
Vitamin B (μg/d) 2.4 2.6
12
Vitamin C (mg/d) 75 85
Calcium (mg/d) 1,000 1,000-1,300
Iron (mg/d) 18 27
Phosphorus (mg/d) 700 700
Selenium (μg/d) 55 60
Zinc (mg/d) 8 11
Applies to women >18 years old. Data from Otten J. J, Pitzi Hellwig J, Meyers L.
D, Editors. Dietary Reference Intakes. The essential guide to nutrient
requirements. Washington, DC: National Academies Press; 2006.
THINGS TO AVOID
 Alcohol
 Excessive caffeine
 Raw meats (this may contain listeria which can cause infection to both
mother and foetus).
 Seafood's (e.g. sword fish, wild mackerel, shark which may contain mercury
that can cause brain damage to the foetus).
 Uncooked processed meats
 Unpasteurized dairy
 PICA (this is regularly craving or consumption of non-food material).

BREASTFEEDING
Breastfeeding, also called nursing, is the process of feeding a mother’s breast milk
to her infant, usually directly from the breast for nourishment. It is an unequalled
way of providing ideal food for the healthy growth and development of infants. It
is also an integral part of the reproductive process with important implications for
the health of mothers. As a global public health recommendation, infants should
be exclusively breastfed for the first six months of life to achieve optimal growth,
development and health. (Global strategy on infant and young child feeding,
WHA55 A55/15, paragraph 10).
Exclusive Breastfeeding
Exclusive breastfeeding is defined as no other food or drink, not even water,
except breast milk (including milk expressed or from a wet nurse) for 6 months of
life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and
medicines) (Nkala T. E. and Msuya S. E., 2011).
BREAST-MILK
 Breast milk is the ideal food for infants, which contains all the nutrients that
an infant needs in the first six months of life.
  It is easily digested and efficiently used, it contains bioactive factors that
augments the infant’s immature immune systems.
 It is safe, clean and contains antibodies which help protect against many
common childhood illnesses.

BREAST-MILK COMPOSITION
Breast milk has three different and distinct stages: colostrum, transitional milk,
and mature milk.

Colostrum

 Colostrum is the first stage of breast milk and it is special.

 It occurs during pregnancy and lasts for 2-3 days after the birth of the baby
and produces in small amount about 40-50ml on the first day (Casey C, et al
1986).
 It is either yellowish in color and it is much thicker than the milk that is
produced later in breastfeeding.
 It is rich in white cells and antibodies, especially secretory immunoglobulin
A (sIgA) and contains a larger percentage of protein, minerals and fat-
soluble vitamins (A, E & K) than later milk.
 Immunoglobulin are antibodies that pass from the mother to the baby and
provide passive immunity for the baby.
 Passive immunity protects the baby from a wide variety of bacterial and
viral illnesses.
 Vitamin A is important for protection of the eye and for the integrity of
epithelial surfaces and often makes the colostrum yellowish in color.
 Other feeds given before breastfeeding is established are called prelacteal
feeds.

Transitional milk

 Occurs after colostrum and lasts for approximately two weeks.

 The content of transitional milk includes high levels of fat, lactose, and
water-soluble vitamins. 
  About 500-800ml per day is produced and it contains more calories than
colostrum.

Mature milk

 Is the final milk that is produced.

 90% of it is water, which is necessary to keep the infant hydrated.
 The other 10% is comprised of carbohydrates, proteins, and fats which are
necessary for both growth and energy.

There are two types of mature milk:

 Fore-milk (this type of milk is found during the beginning of the feeding and
contains water, vitamins, and protein, its grey in colour)
 Hind-milk (this type of milk occurs after the initial release of milk that is
towards the end of feeding. It contains higher levels of fat and is necessary
for weight gain)
 Both fore-milk and hind-milk are necessary when breastfeeding to ensure
the baby is receiving adequate nutrition to grow and develop properly. 

 Energy
o Breast-milk contains about 70kcal per 100ml (WHO, 2012)
 Fat
o It contains about 3.5g of fat per 100ml of milk.
o Rich in docosahexaenoic acid (DHA) and arachidonic acid (ARA) a long chain
polyunsaturated fatty acids for the neurological development of a child.
 Carbohydrate
o Lactose is a special milk sugar, which is about 7g per 100ml of breast-milk.
o Contains human milk oligosaccharides, which are complex sugars which
alter the gut bacteria of the infant, to protect against infection.
 Protein
o Breast-milk contains a balance amino-acids which makes it more suitable
for a baby.
o Protein concentration in breast-milk is 0.9g per 100ml, which is lower than
animal milk.
o It contains less casein which is much softer and more easily-digested curds
than that in other milk.
 o Among the whey or soluble proteins, human milk contains more alpha-
lacto-albumin; cow milk contains beta-lactoglobulin which is absent in
breast-milk and to which infant can become intolerant (Jones and Barlett,
2004).
 Vitamins
o Breast milk normally contains sufficient vitamins for an infant unless the
mother herself is deficient. (WHO 2002).
o The exception is vitamin D. The infant needs exposure to sunlight to
generate endogenous vitamin D.
o Iron & zinc are present in relatively low concentration but their
bioavailability & absorption is high provided that maternal iron status is
adequate, full term infants are born with a store of iron to supply their
needs; only infants born with low birth weight may need supplements
before six months (Carnadas et al. 2006).
o Delaying clamping of the cord until pulsations have stopped (approximately
3 minutes) has been shown to improve infants iron status during the first
six months of life (Chaperro C.M. et al, 2006).

ANTI –INFECTIVE FACTORS IN BREAST-MILK

o Immunoglobulin: coats the intestinal mucosa & prevents bacteria from

entering the cells.
o White blood cells which can kill micro-organisms.
o Whey protein (lysozyme & lactofermin) which can kill bacteria, viruses &
fungi.
o Oligosaccharides which prevent bacterial from attaching to mucosal
surfaces (Hanson 2004).

FACTORS AFFECTING BREAST MILK

o INTENSE EXERTION: increases lactic acid in breast milk which alters milk
taste.
o ALCOHOL INTAKE: alteration of milk taste and causes baby to sleep.
o CAFFIENE INTAKE: causes irritability and wakefulness in the baby. It
interferes with bioavailability of iron in breast milk.
o SMOKING: nicotine alters smell and taste of milk and reduces milk volume.
o PARTICULAR FOODS: infants who develop food allergies, the offenders may
be from the mother’s intake of eggs, fish and peanut.
HOW TO BREASTFEED

Breastfeeding is a skill that you and your baby learn together, and it can take time
to get used to. There are lots of different positions you can use to breastfeed. You
can try different ones to find out what works best for you. You just need to check
the following points:

Guiding Questions

o Are you comfortable? It's worth getting comfortable before a feed. Use
pillows or cushions if necessary. Your shoulders and arms should be
relaxed.
o Are your baby's head and body in a straight line? It's hard for your baby to
swallow if their head and neck are twisted.
o Are you holding your baby close to you, facing your breast? Supporting
their neck, shoulders and back should allow them to tilt their head back and
swallow easily.
o Always bring your baby to the breast and let them latch themselves. Avoid
leaning your breast forward into your baby's mouth, as this can lead to
poor attachment.
o Your baby needs to get a big mouthful of breast. Placing your baby with
their nose level with your nipple will encourage them to open their mouth
wide and attach to the breast well.
o Try not to hold the back of your baby's head, so that they can tip their head
back. This way your nipple goes past the hard roof of their mouth and ends
up at the back of their mouth against the soft palate.

HOW TO LATCH YOUR BABY ON TO YOUR BREAST

o Hold your baby close to you with their nose level to the nipple.
o Let your baby's head tip back a little so that their top lip can brush against
your nipple. This should help your baby to make a wide, open mouth.
o When your baby's mouth is open wide enough their chin should be able to
touch your breast first, with their head tipped back so that their tongue can
reach as much of your breast as possible.
o With your baby's chin firmly touching your breast and their nose clear, their
mouth should be wide open. When they attach, you should see much more
 of the darker nipple skin above your baby's top lip than below their bottom
lip. Your baby's cheeks will look full and rounded as they feed.

BREASTFEEDING POSITIONS

 Cradle hold: This is the probably the most popular breastfeeding position.
However, if you've had a caesarean, this may be uncomfortable as your
baby lies across your tummy near the scar (try lying on your side or the
rugby hold instead). For the cradle hold, sit in a comfy chair with arm rests,
or a bed with cushions or pillows around you.

Cradle Hold Positioning

o Lie your baby across your lap, facing you.

o Place your baby's head on your forearm – nose towards your nipple. Your
hand should support the length of their body.
o Place your baby's lower arm under yours.
o Check to make sure your baby's ear, shoulder and hip are in a straight line.
o Note, if you're sitting on a chair, rest your feet on a stool or small table –
this will stop you from leaning forward which can make your back ache.

 Lying on your side: This is a good position if you've had a caesarean or

difficult delivery, or if you're breastfeeding in the middle of the night.

Lying on your Side Positioning

o Start by getting comfy lying on your side. Your baby lies facing you, so you
are tummy to tummy. Check to make sure your baby's ear, shoulder and
hip are in a straight line – not twisted.
o Put some cushions or pillows behind you for support. A rolled up baby
blanket placed behind your baby will help support them. If you've got a
pillow under your head, make sure it's not too close to your baby's head or
face.
o Tuck the arm you're lying on under your head or pillow (ensuring your
baby's position isn't altered by the pillow) and use your free arm to support
and guide your baby's head to your breast.
  Rugby hold (or the ‘clutch’): The rugby hold is a good position for twins as
you can feed them at the same time, as well as caesarean babies as there's
no pressure on the tummy and scar area.

Rugby hold Positioning

o Sit in a chair with a cushion or pillow along your side.

o Position your baby at your side (the side you want to feed from), under
your arm, with their hips close to your hips.
o Your baby's nose should be level with your nipple.
o Support your baby's neck with the palm of your hand.
o Gently guide them to your nipple.

BENEFITS OF BREASTFEEDING TO THE BABY

o Breast milk provides the ideal nutrition for infants. It contains all the

nutrient the baby needs to grow for the first 6 months. And it's all provided
in a form more easily digested than infant formula.
o Breast milk contains antibodies that help your baby fight off viruses and
bacteria, also, babies who are breastfed exclusively for the first 6 months,
without any formula, have fewer ear infections, respiratory illnesses, and
bouts of diarrhea. Also, prevention of SIDS (sudden infant death syndrome).
o Breastfeeding has been linked to higher IQ scores in later childhood in
some studies. What's more, the physical closeness, skin-to-skin touching,
and eye contact all help your baby bond with you and feel secure.
o Breastfed infants are more likely to gain the right amount of weight as they
grow rather than become overweight children.

BENEFITS OF BREASTFEEDING TO THE MOTHER

o It releases the hormone oxytocin, which helps your uterus return to its pre-
pregnancy size and may reduce uterine bleeding after birth.
o Breastfeeding also lowers your risk of breast and ovarian cancer. It may
lower your risk of osteoporosis too.
 o Since you don't have to buy and measure formula, sterilize nipples, or
warm bottles, it saves you time and money. It also gives you regular time to
relax quietly with your newborn as you bond.
o Breastfeeding burns extra calories, so it can help you lose pregnancy
weight faster.

ABC OF BREASTFEEDING

A = Awareness

o Watch for your baby's signs of hunger, and breastfeed whenever your baby
is hungry.
o This is called "on demand" feeding.
o The first few weeks, you may be nursing eight to 12 times every 24 hours. 
o Hungry infants move their hands toward their mouths, make sucking noises
or mouth movements, or move toward your breast.
o Don't wait for your baby to cry. That's a sign he's too hungry.

B = Be patient.

o Breastfeed as long as your baby wants to nurse each time.

o Don't hurry your infant through feedings. Infants typically breastfeed for 10
to 20 minutes on each breast.

C = Comfort

o This is key. Relax while breastfeeding, and your milk is more likely to "let
down" and flow.
o Get yourself comfortable with pillows as needed to support your arms,
head, and neck, and a footrest to support your feet and legs before you
begin to breastfeed.

NUTRITIONAL REQUIREMENT IN BREASTFEEDING

 Energy requirement
 o An additional 500 Kcal for the first six months and 400 Kcal during the next
six months, are required for a lactating mother (Guidelines for perinatal
care, 2012).
o If the extra demand for energy is not met from dietary sources, then the
reserved fat stores will be used instead.
 Protein Requirement
o According to Dietary Guideline for Americans 65g protein per day which is
important for the baby’s growth
 Iron
o Sufficient iron intake helps maintain energy and prevent fatigue in
breastfeeding mothers.
o Babies experience tremendous growth in the 4 month which depletes their
iron stores. American Academy of Pediatrics recommends that exclusively
breastfed babies should be given iron supplements.
 DHA
o This is essential for the development of the retina of the eye, brain and
bones.
o It plays a major role in the psychomotor neurodevelopment in the first
months of life.
o Sources; fish (e.g. sardines) and fish oil, nuts, seed oils etc.
 Iodine
o WHO/UNICEF recommends 200 microgram per day, to ensure a milk
content of about 100-150µg/100ml of breast milk.
o Sources; iodized salt, sea foods, vegetables grown in iodine rich soil etc.

RECOMMENDED DAILY DIETARY ALLOWANCES FOR BREASTFEEDING MOTHERS

Nutrients lactation
Vitamin A (μg/d) 1300
Vitamin D (μg/d) 15
Vitamin E (mg/d) 19
Vitamin K (μg/d) 90
Folate (μg/d) 500
Niacin (mg/d) 17
Riboflavin (mg/d) 1.6
Thiamin (mg/d) 1.4
Vitamin B (mg/d) 2
6
Vitamin B (μg/d) 2.8
12
Vitamin C (mg/d) 120
Calcium (mg/d) 1000
Iron (mg/d) 10
Phosphorus (mg/d) 700
Selenium (μg/d) 70
Zinc (mg/d) 12

REFERENCES
 Angueira AR, Ludvik AE, Reddy TE, Wicksteed B. et al. New insights into
gestational glucose metabolism: lessons learned from 21st century
approaches. Diabetes. 2015; 64:327–334. [PMC free article] [PubMed]
[Google Scholar]
 Butte NF. Carbohydrate and lipid metabolism in pregnancy: normal
compared with gestational diabetes mellitus. Am J Clinical Nutrition. 2000;
71:125S. [PubMed] [Google Scholar]
 Brizzi P, Tonolo G, Esposito F. et al. Lipoprotein metabolism during normal
pregnancy. Am J Obstet Gynecol. 1999; 81:430.[PubMed] [Google Scholar]
 Newbern D, Freemark M. Placental hormones and the control of maternal
metabolism and fetal growth. 2011; 18:409–416. [PubMed] [Google
Scholar]
 Mazaki-Tovi S, Kanety H, Pariente C. et al. Insulin sensitivity in late
gestational and early postpartum period: the role of circulating maternal
adipokines. Gynecology Endocrinol. 2011; 27:725–731. [PubMed] [Google
Scholar]
 Michelle A.K., and Priya R. nutrition Recommendations in Pregnancy and
Lactation. Medical Clinical North America. 2016 November; 100(6): 1199-
1215.
 Guidelines for perinatal care. 7th American College of Obstetricians and
Gynecologists; Washington, DC: 2012
 Katz D.L. Diet, Pregnancy, and Lactation. Nutrition in clinical Practice. 2nd
edition, Philadelphia: Lippincott Williams & Wilkins; 2008:299-309
 Procter, S. B., and C. G. Campbell. “Position of the Academy of Nutrition
and Dietetics: Nutrition and Lifestyle for a Healthy Pregnancy Outcome.”
Journal of the Academy of Nutrition and Dietetics 114, no. (2014): 1099-
1103
 Trumbo P, Yates A.A., Poos M. food and Nutrition Board, Institute of
Medicine: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat,
fatty acids, Cholesterol, Protein, and Amino Acids. National Academies
Press; Washington, DC: 2002. SS.