1. Nutrition for Pregnancy, Breastfeeding, and Infancy
Jamie Pope, Steven Nizielski, and Alison McCook
NUTRITION
for a Changing World
FIRST EDITION
Chapter 17
Nutrition for Pregnancy, Breastfeeding, and Infancy
Nourishing Mother and Baby
© 2016 by W. H. Freeman and Company & Scientific American

3. Chapter 17
Objectives
Discuss the recommendations and rationale for appropriate weight gain during pregnancy
Define small for gestational age (SGA) and describe consequences of a small-for-gestational-age birth weight
Compare energy and nutrient needs during pregnancy and lactation
Identify foods and beverages that should be avoided during pregnancy
Identify at least five benefits infants derive from breast-feeding
Describe appropriate growth patterns in the first two years of life
Discuss timing and rationale for the introduction of solid foods into an infant’s diet

4. Delaying umbilical cord clamping after birth may boost baby’s iron status.
Delaying cord clamping by 2 to 3 minutes significantly decreased iron deficiency at the age of 4 to 6 months.
(Rarely practiced unless specifically requested by the parent)
Usually, within seconds of a birth, obstetrical care providers clamp the umbilical cord connecting mother to baby, severing the blood flow between them. As Certified Nurse Midwife Judith Mercer’s research has shown, however, delaying the clamping of the umbilical cord by several minutes can provide benefits. Not only does the cord continue to provide blood and oxygen to the newborn in the event of a trauma, but it also increases the baby’s stores of iron—crucial for the development of certain types of brain cells—yet a nutrient in that some babies may become deficient of, as breast milk is not naturally rich in iron.

5. Pregnancy encompasses the time between fertilization and birth.
Umbilical cord
Supplies nutrients and oxygen; removes waste
Placenta
Allows for exchange between maternal and fetal circulation
Uterus
Muscular organ that holds developing fetus
Full term pregnancy is considered anywhere from 38–40 weeks.
Review implantation bleed = why some women don’t figure out they are pregnant
The primary purpose of the umbilical cord is to supply nutrients and oxygen to a developing baby during pregnancy, the period from fertilization to birth. Starting about five weeks after fertilization, the umbilical cord develops and then supplies the fetus with nutrients and oxygen and removes waste until it is clamped after birth. The fetus is carried in a fluid-filled amniotic sac in the muscular organ known as the uterus. The umbilical cord connects the fetus to the placenta, which is attached to the uterus.

6. Pregnancy is dated from the first day of the woman’s last menstrual period, typically two weeks before fertilization.
See notes in next slide

7. Full-term pregnancies last between 38 and 42 weeks.
Gestation
Period of development from fertilization to birth
Embryo
Between 2 to 8 weeks after fertilization
Organs and vital systems begin to develop
Fetus
After 8 weeks of fertilization
Organs continue to mature
Pregnancy divided into trimesters
First trimester: 1 to 13 weeks
Second trimester: 14 to 26 weeks
Third trimester: 27 to 40 weeks
Pregnancy begins when a woman’s egg is fertilized by a sperm, forming a zygote that develops into an embryo and then a fetus. Between two and eight weeks after fertilization, as the organs and vital systems begin to develop, a developing human is referred to as an embryo. At the tenth week of pregnancy (eight weeks after fertilization), the developing human is called a fetus, and its organs mature as it puts on significant amounts of weight (from less than one ounce to between about seven and eight pounds at birth). The entire period of development from fertilization to birth is called gestation. Full-term pregnancies last between 38 and 42 weeks, and are, on average, about 40 weeks long, calculated from the first day of the woman’s last menstrual period. Pregnancy is split into three periods called trimesters: weeks 1 to 13 are considered the first trimester; weeks 14 to 27 compose the second trimester; and weeks 28 to 40 make up the third trimester.

8. Pregnancy results in gradual yet significant changes in the body with altered nutritional needs.
Increased heart and breathing rate
Increased blood volume
Decreased gastrointestinal motility
Increased energy demands and needs
Increased use of fatty acids as fuel
A pregnant woman’s body makes gradual yet significant changes, which alter her nutritional needs, to support the growth of the fetus.
Heart works harder and pumps more blood throughout her body—her blood volume typically increases by about 50%. Breathing rate increases.
Gastrointestinal motility decreases, slowing the passage of food and potentially causing constipation, a common complaint during pregnancy.
Metabolic rate is also affected, and subsequent energy demands increase between 5% and 20% due to the oxygen demands of the developing fetus and maternal support tissues. A pregnant woman’s energy needs thus increase to compensate. Because a fetus prefers glucose as a primary fuel source, the mother’s body provides glucose to her developing baby from the food she digests and uses predominantly fatty acids to fuel her own needs.

9. Appropriate weight gain during pregnancy is important for the health of mother and baby.
In 2009, the Institute of Medicine re-examined the guidelines on weight gain and recommended that women should ideally not only have a healthy BMI when they conceive, but that they should gain weight within a certain range that depends on whether they go into pregnancy underweight, at normal weight, overweight, or obese.

11. 47.5% of women gained excessive amount of weight.
11/5/15 CDC report: Pregnant Women Gain Too Much Weight in the U.S., Risk Maternal and Infant Health
47.5% of women gained excessive amount of weight.
20% gained inadequate amounts of weight.
~ 33% of women gained appropriate amount of weight.
More than half of all women are overweight (defined as a body mass index [BMI] over 25) or obese (BMI over 30) when they become pregnant. Still others gain too much weight during pregnancy—both of which can put the mother and the baby’s health at risk, according to recent research.

12. If a woman weighs 130 lbs prior to pregnancy and is 53” tall (BMI = 23), what should her weight be at the end of pregnancy?
135–150 lbs
145–155 lbs
155–165 lbs
158–170 lbs
Answer is C.

13. Inadequate or excessive weight gain has consequences for both mother and baby.
Underweight women and those who fail to gain sufficient weight during pregnancy can also potentially compromise the health of their babies by increasing the risk that they will be born preterm, meaning younger than 37 weeks, or born too small for their age (small for gestational age, or SGA).
SGA is defined as a birth weight that is below the 10th percentile of gestational age.

14. When I was born I was a: Full-term infant
Pre-term infant (<37 weeks)
I’m not sure.

15. My birth weight was: < 5.5 lbs 5.5 lbs–7lbs 12oz
7lbs 12oz–8lbs 12oz
> 8lbs 12 oz
Don’t know

16. Being underweight and insufficient weight gain in pregnancy increase the risk babies will be born preterm or SGA.
Preterm: younger than 37 weeks
Small for gestational age (SGA)
Birth weight below 10th percentile
At higher risk for stillbirth and dying
Increased risk of hypertension, diabetes, and heart disease as adults
Insufficient energy and nutrient intake increases risk of low-birth-weight baby (< 5.5 lbs)
SGA infants are not only at a higher risk of stillbirth and dying, they also have a heightened risk for medical conditions such as hypertension, diabetes, and heart disease as adults. With new and advanced medical technologies, babies born prematurely or SGA are more likely to survive—and thrive—than in years past.
Because of the risk of not gaining enough weight, even overweight or obese pregnant women should not “diet”; doing so increases the risk of delivering a low-birth-weight baby who has not received sufficient nutrition.

17. Classification of Infants by Birth Weight and Gestational Age
LBW babies: Mississippi has the highest rates; Massachusetts and Utah have the lowest.
Infants are considered to be appropriate for gestational age when their birth weight falls within the 10th to 90th percentile range. Infants born SGA are at increased risk of health problems at birth and as adults.

18. There are four main factors that influence birth weight.
The duration of the pregnancy
The weight status of the mother before conception
The amount of weight gained during pregnancy
Whether the mother smoked during pregnancy
The four main factors that influence birth weight are: (1) the duration of pregnancy; (2) the weight status of the mother before conception; (3) the amount of weight the mother gained during pregnancy; and (4) whether the mother smoked during pregnancy.
Other factors: poverty, access to care, lifestyle issues–drugs/ETOH

19. Eating well to sustain the fetus involves establishing a healthy lifestyle before conception occurs.
Healthy prenatal lifestyle includes the following
Being physically active
Eating well
Making responsible choices
Not smoking
Getting regular medical care
Fertility improved with
healthy lifestyle
Unless otherwise advised by a health care provider, pregnant women can and should stay active throughout their pregnancies.
Eating well to sustain the fetus involves establishing a healthy lifestyle far before conception occurs. A woman who is physically active, eats well, makes responsible choices by not smoking or using harmful substances, and gets regular medical care is much more likely than a less healthy woman to be fertile, that is, to have the ability to produce offspring and have a healthy pregnancy.

20. Chloe is 9 weeks pregnant, so how many extra calories does she need per day?
Minimal
250
340
450
Correct answer is A. Most students think calorie needs increase even this early in pregnancy.

21. Women should increase their calorie intake gradually using nutrient-dense foods.
Energy needs do not increase during early pregnancy.
Important to choose nutrient-dense foods
Increase of ~340 kcal/day in the second trimester
Increase of ~450 kcal/day in the third trimester
Increase in calories greater for underweight woman
Increase in calories less for overweight woman
Appropriate weight gain is better gauge of appropriate intake than counting daily calories.
Typically, a pregnant woman only needs to start consuming more calories after the first trimester, because early in pregnancy, the developing fetus is comparatively small in relation to the mother’s body mass. In general, in the second and third trimesters, pregnant women need between 2,200 and 2,900 total calories a day; the exact number depends on prepregnancy weight and the mother’s activity level. Women should increase their caloric intake gradually using nutrient-dense foods. Ideally to meet increased energy demands, women should eat on average an extra 340 calories per day in the second trimester and an extra 450 kcal per day in the third trimester. (Underweight women need more calories since they should gain more weight; overweight women need fewer. Physically active women require more calories to offset expenditure.)

22. Recommended Energy and Nutrient Intakes During Pregnancy and Lactation
This graph compares the recommended intakes for women ages 19 to 30 years old who are in the third trimester of pregnancy and in the first six months of lactation as compared to their recommended intake when not pregnant or lactating. Note increase in nutrient needs.
Ultimately, pregnant women need only 15% more total calories than nonpregnant women, but they need about 50% more of some nutrients such as protein, folate, zinc, iodine, and iron.

23. Pregnant women can meet most of their nutritional requirements through food.
Dietary supplement recommendations
Follow advice of doctor or midwife
Iron universally recommended
Prenatal multivitamin/mineral supplements
For inadequate diet or high-risk pregnancies
Avoid supplements with more than recommended intake levels
Vegans should consider additional vitamin D, iron, and vitamin B12.
Iron universally recommended but can be included in PNV.

24. Increased needs for protein, folate, zinc, iodine, and iron
Ultimately, pregnant women need ~15% more calories and 50% more of some nutrients.
Increased needs for protein, folate, zinc, iodine, and iron
USDA ChooseMyPlate is a health and nutrition resource for pregnant and breastfeeding women
ChooseMyPlate.gov
Personalized daily food plan
One excellent resource for pregnancy meal planning is the Health & Nutrition Information for Pregnant & Breastfeeding Women on the United States Department of Agriculture (USDA) ChooseMyPlate.org website, which provides a personalized daily food plan based on age, height, weight, physical activity level, and stage of pregnancy or breastfeeding status.

25. During which trimester do most of the critical (growth) periods occur?
1st trimester
2nd trimester
3rd trimester
Correct answer is A.

26. Consuming inadequate nutrients or excess amounts can put the baby at risk for birth defects and other anomalies, especially during critical periods.
Times of accelerated growth called critical periods are genetically determined pathways that direct the development of specific cell types, organs, and tissues and that occur primarily in the first trimester.
Even if she eats enough calories, a woman who does not consume adequate nutrients during pregnancy—or who consumes excess amounts—can put her baby at risk for birth defects and other anomalies, particularly if these discrepancies occur during periods of intense or accelerated fetal development known as critical periods. Critical periods are genetically determined pathways that direct the development of specific cell types, organs, and tissues. Disruption of growth or development during a critical period (from nutritional problem or toxic substance) may be irreversible.

27. The B-vitamin folate is a key nutrient before and during pregnancy for new cell development.
Women 15 to 45 years of age, even if not pregnant, need 400 mcg/day.
During pregnancy, women need 600 mcg/day.
Folate deficiency leads to
Birth defects, fetal growth problems, autism, neural tube defects
Synthetic supplemental form is folic acid.
In 1998, U.S. FDA began requiring grain fortification.
Rate of neural tube defects has dramatically decreased since mandatory fortification of food products in 1998—over 1,000 fewer babies are born with neural tube defects since this mandate was put into effect.
Since over 50% of babies are unplanned, all childbearing women should take 400 mcg of folic acid a day.
Folate (the synthetic form of which is called folic acid), a water-soluble B vitamin, is one of the key nutrients mothers-to-be need before and during pregnancy, as it is crucial for the development of new cells. Folate deficiency is associated with fetal growth problems, birth defects, schizophrenia, and autism; in addition, women who don’t get enough folate during the first 12 weeks of pregnancy are up to 70% more likely to give birth to babies with neural tube defects, such as spina bifida.
The CDC recommends that all women between the ages of 15 and 45 years—even if they are not pregnant—consume a daily dose of 400 micrograms of folic acid in a multivitamin or the equivalent through folate-rich foods. This recommendation applies to all women of child-bearing age because half of U.S. pregnancies are unplanned, and birth defects from folate deficiency develop as early as three to four weeks into pregnancy, before most women even know they are pregnant. During pregnancy, women should consume the equivalent of 600 micrograms of folate daily from foods or supplements. To help women meet these requirements, in 1998 the U.S. Food and Drug Administration began requiring food manufacturers to add folic acid to common grain products such as breads, cereals, flours, and pastas.

28. Inadequate vitamin A impacts development, but too much can increase the risk of birth defects.
Need 770 mcg/day during pregnancy
Not to exceed the UL of 3,000 mcg/day
Stop taking medications that contain vitamin A
Too little can lead to developmental problems
Too much can lead to birth defects like facial and heart deformities
Not associated with beta carotene
Too little vitamin A can cause developmental problems, and too much can also cause birth defects such as facial and heart deformities. Women can thus keep the risk of vitamin A toxicity low by meeting their needs through the consumption of bright orange, deep yellow, and light red vegetables and fruits that are rich in the vitamin A precursor, beta carotene.
The Institute of Medicine recommends that pregnant women between the ages of 19 and 50 years consume 770 micrograms of vitamin A per day, not to exceed the Tolerable Upper Intake Level of 3,000 micrograms per day, and stop taking medications that contain vitamin A. The precursor to vitamin A, beta carotene, however, does not seem to have the same potential adverse effects.

29. Iron deficiency is the most common nutritional inadequacy in pregnancy.
Needs increase by 50% during pregnancy
Iron needs increase significantly during pregnancy due to increases in maternal hemoglobin production and storage by fetus.
27 mg/day during pregnancy vs. 18 mg/day for adult women
Most woman consume just over half this amount.
It is difficult to achieve the recommended intake through food alone.
Supplements of 30 mg/day recommended during the second and third trimesters
Without enough, mothers risk iron-deficiency anemia and babies with low birth weight.
Most common deficiency in pregnant women
Especially if begin pregnancy with low iron stores and insufficient intake during pregnancy
30 mg supplemental iron recommended for second and third trimesters
Even higher requirements for vegetarians
Iron deficiency is the most common deficiency in pregnant women. Iron is used to make hemoglobin, the molecule that transports oxygen through blood, and pregnant women vastly increase their production of hemoglobin to supply oxygen to their fetuses and to help build a fetal blood supply. The daily recommended intake of iron for pregnant women is 27 milligrams per day, compared with only 15 to 18 milligrams for nonpregnant women, yet national surveys have reported that pregnant women generally consume only 15 milligrams per day—just over half of the recommended amount.
It is difficult for women to meet their increased iron needs from food alone, so supplements of 30 milligrams of iron are typically recommended during the second and third trimesters. Women who don’t take supplements are at an increased risk of suffering from iron- deficiency anemia and are also at risk for giving birth to low-birth-weight babies who become iron-deficient in their first year of life.

30. Many nutrients are important for a healthy pregnancy.
Calcium
Crucial for bone development in fetus and mother’s bone health
Enhanced absorption during pregnancy
Recommended intake is 1,000 mg/day
Vitamin D
Incorporate calcium into bones
Appear to play a role in programming genes to reduce risk of chronic disease later in life
Recommended intake 600 IU/day
Iodine
Essential for normal brain development and growth
Studies show many pregnant women do not meet needs
Recommended intake 220 mcg/day
Calcium is crucial for the formation of healthy bones, and although absorption is enhanced during pregnancy, the recommendation for pregnant women is still 1,000 milligrams daily.
Vitamin D helps to incorporate calcium into bones and also appears to play a role in programming genes in ways that could reduce the risk of chronic diseases; pregnant women should consume 600 IUs (15 micrograms) daily.
Iodine is required for normal brain development and growth, and recent studies indicate that approximately one-third of pregnant women in the United States are marginally deficient in iodine. The Institute of Medicine recommends 220 micrograms per day for pregnant women.

31. Omega-3 fatty acids are critical for the development of the fetal brain.
The amount of omega-3 in the fetus is correlated with amount in the mother’s diet.
No official recommendations
as to amount of omega-3
Some health authorities
recommend 300 mg DHA/day.
Encourage consumption of 8–12 oz fish/week
Emphasize low-mercury fish
Excess mercury increases risk of CNS defects and slows cognitive development.
Pregnant women should avoid shark, swordfish, king mackerel and tilefish.
The omega-3 fatty acids, such as EPA and DHA, are critical for the development of the fetal brain. During pregnancy, the placenta transfers nutrients from the mother to the fetus. The amount of omega-3 fatty acids in the fetus is correlated with the amount consumed by the mother, underscoring the importance of adequate nutrition. Although the U.S. government has not made official recommendations about omega-3 intake during pregnancy, several organizations recommend that pregnant women consume 300 mg of DHA daily—yet most women do not meet this recommendation. Cold-water fish are a great source of these omega-3 fatty acids and thus recent recommendations encourage pregnant women to consume 8 to 12 ounces of fish each week.
Because of concerns about mercury contamination in some types of fish, pregnant women are told to choose low-mercury fish and avoid fish that have potentially high levels of mercury, such as shark, swordfish, king mackerel, and tilefish. Women who consume too much mercury during pregnancy are more likely to give birth to babies with central nervous system defects and slow cognitive development.
They can safely enjoy salmon, cod, shrimp, sardines, anchovies, and trout, and are advised to limit albacore tuna and tuna steak to six ounces a week.

32. There are issues during pregnancy that may compromise nutrition and health.
Morning sickness from hormonal changes
Nausea and vomiting
Food aversions
Higher risk for pica
Eating disorder characterized by ingestion of nonfood substances
May be a sign of anemia
Gestational diabetes in ~18% of pregnancies
Elevated blood glucose that passes to the fetus
Risk of large-for-gestational-age infant
Generally resolves after pregnancy
Can increase risk of type 2 diabetes later in life
Some women have trouble getting the nutrients they need because they suffer from morning sickness, triggered by hormonal changes that can cause nausea and vomiting in the first trimester and may sometimes cause unique food aversions.
They are also at a heightened risk for pica, an eating disorder that causes individuals to want to ingest nonfood substances such as clay, paint chips, paste, plaster, dirt, or hair. Pica may be a sign of anemia.
With new diagnostic criteria and increasing rates of obesity, it is estimated that as many as 18% of pregnant women may develop gestational diabetes which is characterized by elevated levels of blood glucose that pass to the fetus, causing it to be large for gestational age, increasing the risk of complications. Although gestational diabetes generally resolves after pregnancy, it increases the risk that the mother will develop type 2 diabetes later in life.

33. CDC: There is no safe level of alcohol consumption during pregnancy.
Alcohol intake during pregnancy can have serious consequences on the developing fetus and cause fetal alcohol syndrome.
Fetal alcohol syndrome: physical and mental defects observed in infants born to mothers who consumed a significant amount of alcohol during pregnancy
CDC: There is no safe level of alcohol consumption during pregnancy.
Fetal alcohol effects are much milder, probably more widespread as well. Defects occur related to what is developing during alcohol use.
Pregnant women should also avoid alcohol. Fetal alcohol syndrome is a group of conditions causing physical, behavioral, and learning problems in children whose mothers drank heavily during pregnancy. Alcohol consumed by a woman during pregnancy travels through her blood and into the baby’s blood, tissues, and organs, where it breaks down slowly, exposing the fetus to the alcohol for long periods. The CDC says that there is no safe level of alcohol consumption during pregnancy.

34. Pregnant women should limit caffeine consumption.
WHO recommends intake below 300 mg/day.
American College of Obstetricians and Gynecologists recommends < 200 mg/day.
2015 DGAs recommend limiting to 2 cups/day.
8 oz brewed cup of coffee contains ~135 mg.
12 oz caffeine-containing soda contains 40 to 50 mg.
Health care providers might recommend limiting the amount of caffeine consumed because it crosses the placenta into the bloodstream of a developing baby. Although most studies report no adverse effects of maternal caffeine consumption on the infant, there is some evidence that high intakes of caffeine are associated with an in-creased likelihood of SGA births, miscarriage, and childhood acute leukemia. The World Health Organization recommends a maternal caffeine intake of below 300 mg per day and the American College of Obstetricians and Gynecologists recommends less than 200 mg per day. Brewed coffee contains about 135 mg per 8-ounce cup and caffeine-containing soft drinks generally contain between 40 mg to 50 mg per 12 ounce can.

35. Pregnant women are about 20 times more likely to develop listeriosis.
During pregnancy the immune system is suppressed, placing women at increased risk for foodborne illness.
Listeriosis is caused by consuming foods tainted with bacterium Listeria monocytogenes.
Can cause premature birth, miscarriage, fetal death, and newborn illness
Can be caused by eating unpasteurized cheeses, unpasteurized milks and juices, unheated luncheon meats, pâté, and meat spreads
Pregnant women are about 20 times more likely to develop listeriosis than a nonpregnant individual. Listeriosis is a serious infection caused by eating food tainted with the bacterium Listeria monocytogenes, which can cause premature birth, miscarriage, fetal death, and newborn illness, as the bacteria can cross the placenta. To minimize their risk of listeriosis, expecting women should not eat hot dogs or other luncheon meats unless they have been heated to steaming hot. They should also avoid unpasteurized cheeses, such as brie, blue cheeses, camembert, and some fetas; uncooked refrigerated smoked seafood; refrigerated meat spreads and pâtés; and unpasteurized milks and juices.

36. Pregnant women are at higher risk for foodborne illness.
Pregnant women need to be careful to avoid microbial-contaminated foods. Hormonal changes during pregnancy suppress the immune system of the mother. While such changes are necessary for the survival of the fetus, they increase the chance of food-borne infections.

37. Pregnant women are at higher risk for foodborne illness.

38. As an infant, I was: Bottled fed only Breastfed exclusively
Breast and bottle fed
I’m not sure.

39. I was breastfed: Was not breastfed Less than 1 month 1 to 2 months
6 months to 1 year
More than 1 year
More than 18 months
More than 2 years

40. The American Academy of Pediatrics recommends breastfeeding exclusively through to the age of six months.
Almost 80% of newborns in US breastfed
Up from 35% in 2000
Breastfeeding (lactation) has become more common in recent years. Seventy-seven percent of U.S. newborns are breastfed by their mothers, and nearly 50% are breastfed until six months of age—up from just 35% in 2000.
The American Academy of Pediatrics recommends that women exclusively breastfeed their babies through the age of six months, at which point they should continue breastfeeding—ideally to the 1-year mark or beyond—while also introducing complementary solid foods.

41. Lactation is the production and secretion of milk from the mammary glands.
A large portion of the breast is comprised of fat. This varies from woman to woman and doesn’t necessarily affect the amount of milk produced. Likewise, women with small breasts can make as much milk as larger-breasted women.
Most of the visible breast is fat. The ducts you can see here get bigger and mature during pregnancy. The placental hormones block true milk production until about 72 hours PP.
The human breast is a gland made up of connective and fatty tissues that support and protect the milk-producing areas of the breast and give it shape. Shortly after birth, milk is produced in clusters of small sacs called alveoli. The alveoli group together and form lobules. Milk produced in the lobules travels through ducts, which eventually exit the skin in the nipple. The dark area of skin surrounding the nipple is called the areola.

42. Volume varies based on demand Components of breast milk
The composition of breast milk varies depending on the stage of lactation, milk volume, feeding frequency, and differences between women.
Volume varies based on demand
Components of breast milk
Water, carbohydrates, fats, proteins, vitamins, and minerals
Antibodies to fight infections and enhance immunity
Foremilk
Lactose, protein, and water
Hindmilk
More fat than foremilk
Foremilk is thinner to quench thirst, and hindmilk is the fattier dessert. Think of it as skim, 2%, and whole.
The human breast does not store a large amount of milk. In fact, most milk is produced during nursing, based on need. In other words, the volume of milk produced varies with demand—the volume can go down if the mother does not nurse or pump, and the volume may increase if the baby feeds a lot. When the infant sucks on the nipple, the hormones prolactin and oxytocin are released. Prolactin stimulates milk production while oxytocin stimulates contraction (or the “let-down reflex”), which shortens and widens the milk ducts ejecting milk through the duct system and out of the nipples.
The composition of breast milk varies depending on the stage of lactation, milk volume, feeding frequency, and differences between women. However, once lactation is established, the primary components are water (87%), carbohydrates, fats, proteins, vitamins, and minerals. At the beginning of the feeding, the milk contains lactose and proteins, but little fat; it is called foremilk. The end of the feeding produces hindmilk. The hindmilk contains more fat, the main source of energy for the infant. Both are nutritious, but hindmilk has more calories and babies will be more satiated if they get both foremilk and hindmilk during feedings.
Contains antibodies that enhance their ability to fight infections and strengthen their immune systems.

43. Benefits of breastfeeding include:
Improved growth and weight gain for the baby
Lower risk of food allergy
Less asthma risk for the baby
Lower risk of chronic disease later in life
Higher IQ
All of the above
The correct answer is F.

44. There are huge benefits to breastfeeding that affect both the infant and mother.
Breast milk is the ideal infant food. It provides babies with many crucial nutrients, as well as antibodies that enhance their ability to fight infections and strengthen their immune systems. Breast milk is rich in vitamins, full of essential fatty acids for brain development, contains the appropriate balance of proteins and minerals to enhance digestion, and promotes infant oral motor development. Additionally, breastfeeding also reduces the risk of diarrhea and vomiting in infants and mitigates their risk of becoming obese later in life. There is also limited evidence that it may reduce the risk for chronic diseases, such as type 2 diabetes and heart disease, later in life.
There are also documented benefits to breastfeeding, including reductions in incidence of upper respiratory infections in the first two years of life, childhood leukemia, sudden infant death syndrome, and orthodontic problems. Evidence also exists to support higher IQ scores among children who were breastfed for at least 6 months. Plus, breastfeeding is convenient and less expensive than formula feeding, and it plays an essential role in promoting mother-infant bonding. There are added benefits for mothers who nurse that include a reduced risk of ovarian and breast cancer, less risk of type 2 diabetes, and possibly a faster return to pre-pregnancy body weight.

45. Women who are breastfeeding need to replenish nutrient stores and remain healthy to produce enough nutrient-rich milk.
Energy demands increase by approximately:
600 calories/day first six months
Recommended to increase intake by 330 calories
Remaining energy supplied from fat stored during pregnancy
400 calories/day after six months
Energy intake should equal energy in milk produced
Should focus on nutrient-dense foods
Women who are breastfeeding need to replenish their nutrient stores and remain healthy to produce enough nutrient-rich milk. Although lactation increases energy use by about 600 kcal a day during the first six months of breastfeeding, it is recommended that intake be increased by only 330 kcal a day, as the remaining energy will come from fat stored during pregnancy. During the second 6 months of lactation, a woman’s body weight is generally stable and the recommended increase in energy intake is equal to the energy present in the milk produced each day (400 kcal). As with pregnancy, energy needs should be met by consuming nutrient-dense foods.

46. More women are breastfeeding, but there are challenges for some.

47. There are few physical conditions that preclude breastfeeding.
HIV/AIDS
Herpes simplex or chicken pox lesions on nipples
Alcohol or drug addiction
Nipples that have been removed and replaced
Cancer treated with cytotoxic drugs
Things that were NOT on that list:
Breast implants—if placed under the chest wall muscles, they are usually ok.
Smokers
Antidepressants
Soda or caffeine
Occasional wine
There are a few physical conditions that preclude new mothers from breastfeeding their babies. These conditions include HIV/AIDS, herpes simplex or chicken pox lesions on one or both nipples, alcohol or drug ad-diction, nipples that have been removed and replaced, or cancer treated with cytotoxic drugs. Otherwise, most chronic conditions can be managed with drugs that are safe to take while breastfeeding.

48. Formula feeding can be a nutritious adjunct to breast milk.
Designed to duplicate breast milk
Lacks antibodies and other components in breast milk
More expensive
Should not be diluted
Consult physician to select appropriate formula
Nutritionally, breastfeeding is the best option for babies, but it’s not right or possible for every mother. Bottle feeding commercially prepared infant formulas can be a nutritious adjunct to, or replacement for, breast milk. Manufactured under sterile conditions, commercial formulas are designed to duplicate breast milk using sophisticated combination of proteins, sugars, fats, and vitamins.
Although formula provides the basic nutrients an infant needs, it lacks the antibodies and many of the other components that only breast milk contains. Still, some individuals may feel more comfortable with formula feeding. It allows a mother to know exactly how much food the baby is getting, and there’s no need to worry about the mother’s diet or how medications might affect the breast milk. However, formula feeding can be expensive, and formulas should never be diluted to stretch out a supply. Anyone thinking of formula feeding an infant should check with a physician about selecting an appropriate formula.

49. Infants nutritional recommendations vary with age.
Newborn
Vitamin K injection at birth
0 to 6 months of age
Exclusively breastfed or formula-fed
Vitamin D supplements of 400 IU
6 to 12 months of age
Introduce solid foods
Continue breastfeeding or formula-feeding
1 to 2 years of age
Will only gain about 5 pounds
Babies don’t get all of their nutrients through breast milk alone. Parents are advised to supplement their breastfed babies with 400 IU of vitamin D each day starting from the first few days of life. Breastfed babies of vegan or vitamin B12-deficient mothers may also require vitamin B12 supplements. All newborns are also typically given an injection of vitamin K in the hospital after birth. Babies have very little vitamin K, an important blood-clotting vitamin, in their bodies because it crosses the placenta to the developing baby poorly. In addition, though it has recently been recognized that the unborn infant’s gut may contain low levels of certain bacteria that synthesize vitamin K, very little of the vitamin is absorbed from the colon where these bacteria reside.
Infants vary considerably in terms of their growth, development, nutritional needs, and feeding patterns. During the first two to six weeks of their lives, they primarily feed, sleep, and grow. By late infancy, newborn reflexes have gone away and a baby has mastered certain physical tasks that allow him to progress from a diet of exclusive breast milk or formula to foods with an increasingly wide variety of flavors and textures. The ways parents feed their babies not only nourishes them but also helps to promote motor development and establishes key feeding skills, healthy habits, and strong family relationships.

50. Infants typically triple their birth weight and increase in height by 50% by the end of their first year.
Babies grow at different rates because of differing genetic factors and prenatal history, but growth is also an important indicator of adequate nutrition. Inadequate intake of calories or essential nutrients can significantly affect mental and physical development, particularly during the critical periods from birth to one year. Infants should double their birth weight by four to six months and typically triple it by their first birthday. They also grow in length by approximately 50% in their first year.

51. Solid foods are intended to complement—not replace—breast milk or formula.
Solid foods—which the American Academy of Pediatrics advises should be introduced around the age of six months and the World Health Organization advises should be introduced between the ages of four and six months—are intended to complement, but not replace, breast milk or formula. Infants who are exclusively breastfed for around six months have consistently been shown to have a reduced risk of gastrointestinal tract infections and grow and develop as well as infants who have solid foods introduced before six months.
Babies who are fed solid foods before they are ready may be at risk for becoming overweight, developing food allergies, and suffering upset stomachs.

52. Infants should display certain signs of readiness before introducing solid foods.
Hold head up with good control
Sit in a high chair or feeding chair
Diminished tongue thrust
Move food to back of mouth for swallowing
Show an interest in what others are eating
Signify when they are satisfied
Turning head
Refusing to open mouth
According to the American Academy of Pediatrics, a baby may be ready to eat solid foods when she is able to hold up her head and sit in a high chair or feeding seat with good head control. The tongue thrusting reflex that allows a baby to suck efficiently should be diminished enough so that the infant can move food from the spoon to the back of his mouth for swallowing. Typically infants double their birth weight at around four months and weigh 13 pounds or more and may, at that point, be big enough to try solid foods. Finally, babies may indicate a readiness for solid foods when they show an interest in what the family is eating, and can signify when they are satiated, for instance by turning their head when they are full or by refusing to open their mouth.

53. Solid food is best introduced:
Mixed in with formula during the 1st month
6 weeks
4–6 months
After 1 year
Only after stopping breastfeeding
Correct answer is C.

54. Summary
During the 38 to 42 weeks of pregnancy, the developing fetus is supplied with nutrients and oxygen from the mother through the umbilical cord, which connects the fetus to the placenta, which is attached to the uterus.
A woman’s nutrient needs change during pregnancy in order to support the growth of the developing fetus and maternal support tissues.
A woman’s energy needs gradually increase as pregnancy advances, with an average increase of 15%. Nutrient needs increase by as much as 50% for some vitamins and minerals.
The Institute of Medicine provides guidelines for appropriate weight gain during pregnancy based on BMI at conception, to reduce complications during pregnancy and at delivery, as well as to promote the healthy birth weight of a baby.

55. Summary (Cont’d)
Birth weight is influenced by several factors. Infants who are born preterm or are small for gestational age have an increased risk of death, complications, and certain medical conditions as adults.
Insufficient intake of essential nutrients can increase the risk of birth defects, particularly during critical periods of accelerated fetal development.
Folate plays an important role in the prevention of neural tube defects.
Iron needs are increased by 50% during pregnancy, which often warrants supplementation to prevent iron-deficiency anemia that affects oxygen supply and iron status of the fetus.
To reduce the risk of the developing fetus, pregnant women are advised to avoid alcohol, limit their intake of certain fish because of potential mercury contamination, and avoid microbial-contaminated foods.

56. Summary (Cont’d)
The American Academy of Pediatrics recommends that mothers exclusively breastfeed their babies through six months of age and then continue breastfeeding (ideally to one year of age or beyond) while also introducing complementary solid foods according to the infant’s developmental readiness.
Breastfeeding supplies the growing infant with essential nutrients in appropriate proportions, provides antibodies to strengthen immunity, and has many additional benefits for both the mother and baby.
Breast milk may not supply sufficient vitamin D, therefore supplementation for breastfed infants is recommended. Infants who are exclusively breastfed after six months of age may require iron supplementation.
Women who are breastfeeding have increased energy and nutrient needs for milk production, as well as for replenishing nutrient stores.
Infants develop rapidly in the first year of life and require a consistent supply of energy and essential nutrients. Growth is an important indicator of adequate nutrition.