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Maternal and Infant Nutrition

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  • A healthy, varied diet that contains adequate amounts of all the nutrients needed by a mother and her growing fetus (including sufficient iron, calcium and folate) is essential for a healthy pregnancy.  
  • All women of child-bearing age who may become pregnant are advised to take daily supplements (400 micrograms) of folic acid, as this can help to reduce the risk of the baby suffering from a neural tube defect.  Pregnant women should avoid supplements containing vitamin A. 
  • Pregnant women should ensure that their intake of alcohol and caffeine does not exceed current recommendations and minimise their risk of suffering from food poisoning (e.g. by strict use of good food hygiene practices and avoidance of ‘high risk’ foods).  Avoidance of shark, swordfish and marlin and the consumption of no more than 2 portions of oily fish per week is advised because of the levels of potential contaminants in these fish. 
  • Staying physically active during pregnancy is important to promote general health and well-being. 
  • Breast-feeding is the best method of feeding for babies. A varied diet is important whilst breast-feeding to ensure a sufficient intake of all nutrients needed by both the mother and the baby.  Breast-feeding mums are also advised to take supplements containing 10 mcg of vitamin D each day. 
  • By 6 months of age breast or formula milk will be insufficient to meet a baby’s nutrient needs and the process of weaning onto a solid diet should begin.   
  • Non-wheat cereals, fruit, vegetables and potatoes are suitable first weaning foods. Salt should not be added to any foods for babies.  Between 6 and 9 months the amount and variety of foods should be increased to include meat, fish, eggs, all cereals and pulses. 

From the age of 6 months, infants receiving breast milk as their main drink should be given supplements of vitamins A, C and D. 

A varied diet containing adequate amounts of energy and nutrients is essential both before a woman becomes pregnant (conceives), during pregnancy and if she breast-feeds (lactation). The mother’s diet influences the health of the baby in the short-term and perhaps even in the long-term. 

PRECONCEPTION

Being a healthy body weight is important before pregnancy. Being underweight can affect fertility, making it more difficult to conceive. It can also increase the chance of the baby having a low birth weight, which can increase the risk of ill health in early and later life. Being veryoverweight can also affect fertility and increases the risk of complications such as high blood pressure, infections and diabetes during pregnancy.

Folate/folic acid

The vitaminfolate is particularly important before conception and during the first twelve weeks of pregnancy. Extra folate at this time reduces the risk of having a baby with a neural tube defect, such as spina bifida.

All women of child bearing age who may become pregnant are advised to take daily supplements (400 micrograms) of folic acid (the manufactured form of folate), as it is difficult to achieve the extra folate needed through diet alone. This is because the vitamin is important at a time when many women do not realise that they are pregnant. A woman who has already had a baby with a neural tube defect may be advised by her doctor to take a larger supplement (for example 5 mg/day). It is also important to consume foods that are naturally good sources of folate e.g. green vegetables, oranges, and foods that have been fortified with folic acid e.g. some breads and breakfast cereals. 

Alcohol

Women who are trying to become pregnant should drink no more than one to two units of alcohol once or twice a week and avoid binge drinking. 

Caffeine

The Food Standards Agency has advised pregnant women and those women intending to become pregnant to limit their caffeine consumption (see below). 

Fish

The Food Standards Agency (FSA) advises women intending to become pregnant to avoid eating shark, swordfish and marlin and not to eat more than 4 medium-sized cans of tuna or 2 fresh tuna steak a week. This is because the mercury present in thesefish can potentially harm an unborn child’s nervous system.

Advice for men

Giving up or reducing alcohol intake is often recommended for men too. Theminerals zinc and selenium are important in sperm production and a varied diet is important to provide adequate amounts of these nutrients. However, there is little evidence to suggest that supplements of these nutrients will improve fertility.

AFTER CONCEPTION

Contrary to the popular phrase ‘eating for two’, most pregnant women do not need to double their food intake. In fact, it is only during the latter part of pregnancy that extraenergy is needed; an increase of 0.8 MJ or 200 kcals a day in the last 3 months of pregnancy is recommended, although the needs of individual women will vary, depending on how active they are (see below). However, an expectant mother requires a healthy and varied diet to provide her and her growing baby with the full range of nutrients.

Weight gain

A weight gain of 12.5 kg in women of normal pre-pregnant weight is associated with the lowest risk of complications during pregnancy and labour. In practice, however, there is a wide range of weight gains in individual women who have normal and healthy pregnancies, with average weight gains of between 11-16 kg. 

During pregnancy a woman’s nutritional needs increase because the diet must provide sufficient energy and nutrients: 

  • to meet both the mother’s usual needs and provide extra for the growth of the breasts, uterus and placenta  
  • to meet the needs of the growing fetus  
  • for the mother to lay down stores of nutrients to help the growth of the fetus, and for lactation  
  • Nutrients and oxygen pass from the mother’s blood to the fetus from the placenta, via the umbilical cord. 

The recommendation for energy intake (an extra 0.8 MJ/day or 200 kcals during the last 3 months) assumes that, during pregnancy, activity levels fall and women will become more sedentary but this is not always the case. It is difficult to say how much an individual pregnant woman should be eating – the best option is for weight gain and fetal growth to be monitored. 

Iron

Iron needs are increased during pregnancy for the growth of the placenta and fetus. Consequently it is recommended that pregnant women consume plenty of foods containing iron such as red meat, fortified breakfast cereals, pulses, breads and green vegetables. However, there is also an iron saving because of the absence of menstruation (periods) and an increase in iron absorption during pregnancy, so many pregnant women do not need extra iron during pregnancy. But some groups of women (e.g. young women aged 15-18 years) typically have low intakes of iron before becoming pregnant, and are at risk of developing anaemia. Iron deficiency anaemia during pregnancy can increase the risk of the baby having a low birth weight and developing iron deficiency anaemia during the first year or two of life. These women will be prescribed iron supplements and may also be given dietary advice to ensure that their diets contain adequate amounts of all nutrients.

Vitamin A

Vitamin A is essential for good health. However, large intakes during early pregnancy have been linked to birth defects. Women who are pregnant, or who might become pregnant, should not take vitamin A supplements unless they are advised to do so by a health professional. Liver and liver products (e.g. paté) may contain large amounts of vitamin A, so these should also be avoided. 

Harmful bacteria

Listeriosisis a rare flu-like illness caused by bacteria called Listeria monocytogenes. Listeriosis in pregnancy may cause miscarriage, still-birth or severe illness in the newborn baby. Although it is rare in this country, pregnant women are advised to avoid those foods where high levels of the bacteria have occasionally been found, for example paté and blue-veined and soft cheeses such as Brie and Camembert. There is no risk associated with hard cheeses such as Cheddar of Cheshire, or cottage cheese, processed cheese or cheese spread. For similar reasons, it is emphasised that pregnant women re-heat ready-cooked meals (particularly those containing poultry) until they are piping hot and that they wash fruit and vegetables well, especially if they are to be eaten raw (which is also the advice given to the general population). 

Toxoplasmosisis an illness caused by a parasite which can be found in cat faeces. The parasite can also be present in raw meat and occasionally goat’s milk. The illness can in rare cases be passed to the unborn baby via its mother, resulting in a range of problems, some of them serious. As a safeguard, pregnant women should not eat raw or undercooked meat, unpasteurised goat’s milk or goat’s cheese, or unwashed raw fruit and vegetables. Good food hygiene practices should be followed in the kitchen and contact with cat litter trays or soil that may have been fouled by cats should be avoided by wearing gloves. 

Salmonellapoisoning is particularly undesirable during pregnancy, although it is not likely to have a direct adverse effect on the baby. As a precaution, pregnant women should avoid eating raw eggs or food that contains eggs that are raw or partially cooked. Eggs should be cooked until both the white and yolk are solid. Raw meat and chicken can also be a source of salmonella bacteria. All meat, especially poultry, should be thoroughly cooked and it is important to avoid contamination of other foods by washing hands after touching raw meat and by preventing raw meat and poultry from touching or dripping onto other food (e.g. in the fridge), especially that which is already cooked or will be eaten raw. 

Alcohol

Drinkingalcohol during pregnancy can damage the unborn child, so pregnant women may prefer to avoid alcohol. The Department of Health advises that to minimise the risk to the unborn child, women who are trying to become pregnant or are at any stage of pregnancy should not drink more than 1 or 2 units of alcohol once or twice a week, and should avoid heavy drinking sessions. One unit is a small glass of wine, a half pint of ordinary strength beer, lager or cider, or a single 25ml (pub) measure of spirits.

Caffeine

The Food Standards Agency (FSA) advises pregnant women to limit the amount of caffeine they consume to no more than 300 mg a day (around 4 cups of coffee). High levels of caffeine can result in babies having a low birth weight, or even lead to pregnant mothers miscarrying. Caffeine is added to some soft drinks and energy drinks, as well as occurring naturally in foods such as coffee, tea and chocolate.  

How much caffeine is there in foods?  

  • 1 mug of instant coffee contains 100mg caffeine  
  • 1 cup of brewed coffee contains 100mg caffeine  
  • 1 can of ‘energy’ drink contains up to 80mg caffeine  
  • 1 cup of instant coffee contains 75mg caffeine  
  • 1 cup of tea contains 50mg caffeine  
  • 1 chocolate bar (50g) contains up to 50mg caffeine  
  • 1 can of cola contains up to 40mg caffeine  
  • For more information, please visit the FSA’s website. 

Fish

The population guideline recommendation forfish consumption is at least two portions of fish per week, one of which should be oily fish. This recommendation on fish also applies to pregnant and breast-feeding women (but they should limit oily fish to 1-2 servings per week).  Also these groups of women should avoid the large predatory fish marlin, swordfish and shark (because of potential methylmercury exposure). The FSA also advises pregnant women that the amount of tuna eaten should be limited to no more than 2 tuna steaks per week or 4 medium-size cans a week. This is again because tuna may contain mercury, which at high levels can harm a baby’s developing nervous system.

The nutritional basis for these recommendations is that fish consumption, particularly oily fish, decreases the risk ofcardiovascular disease; the effect is thought to be a result of the long chain n-3 (omega 3)polyunsaturates present in oily fish. Furthermore, in pregnancy and lactation, there is a demand on the mother to supply the fetus and infant with long chain n-3 polyunsaturates, required for the development of the central nervous system. No adverse effects of maternal n-3 supplementation have been observed and increased maternal intakes may be of particular importance in groups with a low habitual intake and in lower birth weight populations.

Food allergy

If a mother, father or sibling suffers from allergic disease (such as eczema, asthma or hayfever) it is recommended (as a precaution) that peanuts or foods containing peanuts are avoided during pregnancy and breast-feeding and that infants are not given these foods until the age of 3 years.  For those who do not have a strong family history of allergy, avoiding these foods is not recommended and, in fact, can do more harm than good, as it may be that the tiny amounts encountered via the mother are precisely the quantities required to trigger the baby’s tolerance of the proteins in these foods responsible for allergic reactions.  

Physical activity

Staying physically active during pregnancy is important to promote general health and help to alleviate common complaints during pregnancy such as backache and constipation.  Useful activities include swimming, some forms of yoga, toning and stretching, which can be done at any stage of pregnancy.  Contact sports or exercise with a risk of falling should be avoided and pregnant women must be careful not to become dehydrated, exhausted or too hot.   

LATE PREGNANCY

The estimated average requirement for energy (EAR) increases during the last three months of pregnancy by an average of 0.8 MJ (200 kcal) per day. At this time a woman’s energy expenditure from physical activity is usually reduced. If a mother’s food intake is very low at this stage and if her fat stores are low, the fetus grows more slowly and the baby may have a low birth weight. This may increase the risk of heart disease, diabetes and raised blood pressure many years later, in adult life. 

BIRTH

A normal pregnancy is between 37 and 41 weeks, and full-term babies in the UK on average weigh around 3.3 kg. On average, boys are approximately 300 g heavier than girls. Babies who are born small for their gestational age (low birth weight) or have a low birth weight because they are premature (i.e. their weight is appropriate for their gestational age) may need special feeding in a special care baby unit. 

AFTER THE BABY IS BORN

During pregnancy, while in the womb, the fetus obtains nutrients from its mother via the placenta. Once the baby is born, energy and nutrients are supplied by breast milk or formula milk for the first 4-6 months. The rate of growth at this age is greater than at any other time of life. 

BREASTFEEDING

Breastfeeding is considered to be the best method for feeding babies. Breast milk provides all the energy, liquid and nutrients the baby needs for growth and development.

During pregnancy, hormones cause tissues in the mother’s breast to grow and become ready to secrete milk. After birth, the act of suckling by the baby stimulates the action of hormones which cause milk to be produced and secreted.   

Milk contains energy in the form ofprotein,fat andcarbohydrate Therefore, a mother who is breast-feeding needs extra energy and nutrients. It is important that breast-feeding women have a well-balanced and varied diet and consume plenty offluids. Breast-feeding mums in the UK are advised to increase theirenergy intake.

Studies have shown that in the first three months, mothers of fully breast-fed babies produce about 800 ml of milk a day. The amount is very similar among women all over the world. The production of this quantity of milk uses up about 2.1 MJ (500 kcals) a day and this energy can come from: 

  • the diet (if the mother eats more), 
  • fat stores gained during pregnancy, and/or 
  • energy saved from changes in metabolic rate, or becoming more sedentary. 

For most women, the energy comes from a mixture of these routes and breast-feeding can help to promote the loss of excess weight gained in pregnancy. There are also many other important reasons, including psychological and immunological factors, why women should breast-feed.  It is not advisable to either restrict food intake or to limit the variety of foods during lactation (e.g. by the adoption of ‘faddy’ diets), as this could result in a low intake of important nutrients. 

Composition of breast milk

In the first 3 days after birth, a special form of breast milk called colostrum is secreted. It contains less fat, more protein and more ‘protective’ factors than the breast milk that is produced later. The composition of breast milk also changes as the baby feeds. At the beginning of the feed, the consistency is more watery (called the foremilk), whereas towards the end of the feed the fat content increases (the hindmilk) which provides the baby with energy.  

On average, 100g of human milk provides: 

  • 289 kJ (69 kcal) of energy 
  • 1.3g protein
  • 4.1g fat
  • 7.2g carbohydrate (mainly lactose)
  • 34 mg calcium

In the early weeks after birth, the baby also obtains some nutrients (e.g. vitamin D and iron) from stores it laid down before it was born. 

It is known that breast milk contains special proteins, antibodies, white blood cells and nucleotides which help to protect the baby against infection. It also contains growth factors, hormones and the long chain polyunsaturated fatty acids (PUFA) arachidonic and docosahexanoic acids. There may also be other active substances, which we do not yet know about. Despite the recognised benefits of breast-feeding, in the UK in 2000 only 42% of mothers were breast-feeding at 6 weeks, with this figure dropping to 21% at 6 months. However, the incidence of breast-feeding has increased since the 1980s. 

Whilst breast-feeding it is important to ensure adequate fluid intake.  Breast-feeding women are also advised to take supplements containing 10 micrograms of vitamin D each day.  Peanuts and peanut products do not need to be avoided while breast-feeding unless a baby is at high risk (i.e. has a parent or sibling with allergic conditions such as hayfever, asthma and/or eczema), in which case avoidance while breast-feeding and during the introduction of solid foods may be sensible.   

For further information, visit the Department of Health website. 

INFANT FORMULA

For those mothers who cannot or choose not to breast-feed, an infant formula (‘baby milk’) should be used. Most infant formulas are made from cows’ milk that has been modified to make the protein, fat and carbohydrate similar to that of human milk. Soya formulas are based on soya and it is recommended that they are only used following medical advice. They are sometimes used for infants who cannot tolerate cows’ milk, although such babies may need special ‘hypoallergenic’ milks as soya can also trigger allergy.
 
Unmodified cows’ milk does not provide nutrients in the particular proportions needed by human infants. In infants under 1 year of age, cows’ milk should not be the main drink, as it is a poor source of iron. However, it can be a component of the weaning diet. 

Most infant formulas are powders which must be mixed with water in the correct proportions. The water must be sterilised by boiling (and then cooled), and the bottles must be cleaned carefully and sterilised to prevent contamination by bacteria. Vitamins, minerals and trace elements are added to infant formulas during manufacture to meet the infant’s nutritional needs and to comply with legal requirements. Infant formula does not contain the growth factors, hormones, antibodies and other protective factors found in breast milk, so infections and constipation tend to be more common in bottle-fed compared to breast-fed babies. However, some infant formulas now contain other components that occur naturally in breast milk, such as long chain fatty acids and oligosaccharides. 

The composition, ingredients, and the manufacture of infant formulaes and baby foods is extremely strictly controlled by legislation.  

WATER

Before 6 months fully breast-fed babies do not require additional fluids (including water), unless medically indicated.  Bottle-fed babies may be offered cooled, boiled water in hot weather but this should not be given as a replacement to milk feeds. 

Water from the mains tap in the kitchen should be used and it should always be boiled and cooled for babies under 6 months. Some natural mineral waters have high mineral contents and are not suitable for babies (some bottled waters are suitable for infant feeding and may be labelled as such).  Bottled water is not sterile so will still need to be boiled and cooled before being offered to babies. 

In hard water areas, people sometimes choose to use jug water filters to remove some of the hardness naturally present in tap water.  Although tap water is recommended for reconstituting infant formula, some people may choose to use filtered water; in this instance this must also be boiled and cooled. 

WEANING

By six months of age, milk alone no longer fulfils the baby’s nutrient needs, particularly for iron, and the process of weaning on to a solid diet should begin. It is a time when the body’s systems, notably the gut and kidneys, are rapidly maturing and when neuromuscular coordination should be sufficiently developed to allow the infant to eat solids. Until recently the Department of Health (DH)  advised that weaning  should begin between 4 and 6 months of age. But in line with recent World Health Organisation recommendations (that take into consideration the needs of infants in developing countries) DH currently recommends exclusive breast-feeding for the first six months of age.  Some authorities believe this advice is not necessary for a country such as the UK and there are ongoing discussions concerning the ideal weaning age for both breast- and bottle-fed infants. It is currently agreed that the majority of infants should not be given solids before four months of age and a mixed diet should be offered by six months (COMA, 1994). However, the timing and rate of introduction of weaning should take into consideration the wide individual variation in developmental maturity between infants. Surveys of infant feeding in the UK suggest that in practice solids are frequently introduced before six months and even before 4 months of age (FSA/DH link), although most babies will not benefit from solids before 4 months. 

The initial stage of weaning should aim to accustom the baby to take food from a spoon and the food should be of a smooth consistency and relatively bland. Non–wheat cereals, such as rice, puréed vegetables and fruit, and mashed potato (no added salt) are suitable foods for this first stage. Salt should not be added as the infant’s kidneys are unable to cope with too much sodium. Added sugar should be avoided except small amounts to sweeten sour fruit. Cows’ milk products such as yogurt and custard are suitable early weaning foods. 

It is recommended that children under six months of age should not be given wheat or other gluten-containing cereals such as barley or rye, as early exposure to gluten may increase the risk of coeliac disease. Other potentially allergenic foods, notably eggs and peanuts should also be avoided until 6 months of age. In children from families with a strong history of allergic conditions such as eczema, asthma or hayfever, a longer period of exclusion of certain foods (e.g. peanuts) may be advisable. 

Gradually, different tastes including pulses and pureed meat (which are important sources of iron) can be introduced. Different textures (minced and then chopped) can also be introduced as the baby begins to chew. As the baby gets older and begins to put foods in its own mouth, soft finger foods such as banana or pear or toast can be given. 

Gradually the baby becomes less dependent on milk and by the age of 9-12 months should have progressed to a more adult type of diet with three meals a day containing a wide variety of different foods interspersed with two or three suitable snacks and with milk (around 500 to 600 ml per day of breast, formula or follow-on milk). This should provide an adequate intake of all nutrients. 

Foods/drinks containing vitamin C (e.g. fruit and vegetables, potatoes or fruit juice) should be included with meals to assist iron absorption, particularly if the diet is meat-free.  Continued use of iron-enriched infant formula or a follow-on milk after the first year should be considered if there are concerns about the adequacy of iron in the diet. 

Eggs should be cooked until both the white and yolk are solid.  Raw eggs and food that contains raw or partially cooked eggs should be avoided because of the risk of salmonella poisoning. Whole or chopped nuts should not be given to children under five years old because of the risk of choking. Shark, swordfish and marlin should also be avoided because these fish contain relatively high levels of mercury, which might affect a baby’s developing nervous system. 

Commercial baby foods can make a useful contribution to a mixed weaning diet by complementing family foods. They offer convenience, particularly in the intermediate stages of weaning, and many are fortified with iron, a particularly important nutrient for rapidly developing infants. 

As the baby’s teeth come through, it is important that good dental hygiene begins. Initially teeth can be cleaned gently with a small toothbrush and no paste. The use of toothpaste containing fluoride is important in dental caries prevention as the teeth develop, but in babies and young children very small amounts of toothpaste should be used to avoid excess fluoride ingestion. 

Weaning onto a vegetarian or vegan diet

With appropriate care, varied vegetarian and vegan diets can provide all the nutrients a baby needs for growth and development.  However, such diets can be high in fibre and this may result in low energy intake and interfere with mineral absorption (e.g. iron, zinc, copper).  Vegetarian meals should provide protein from a mixture of sources, and vitamin C to aid iron absorption. Supplements of some nutrients (e.g. vitamin B12) may be needed. 

SUPPLEMENTS

The Department of Health recommends that infants receiving breast milk as their main drink after the age of 6 months should receive supplements of vitamins A, C and D (in the form of liquid drops). Infants receiving at least 500ml of infant formula daily do not require these vitamin drops since the vitamins are already added to the formula.  If babies are consuming infant formula or follow-on milk in smaller amounts, or they are being given cows’ milk, supplements of vitamins A and D should be given. 

It is also recommended that between the ages of one to five years, vitamin A, C and D supplements should be given unless adequate intake and exposure to sunlight can be assured.