Part 2
    Specific nutritional recommendations for your pregnant patient, before, during, and following her pregnancy, as supported by the literature.

     A good and healthy nutrition at least 3 months to one year before pregnancy is an important step, because childbirth requires many resources and in addition to that, the pre-pregnancy nutrition will have a positive effect on the immune system in preparation of pregnancy and is a significant factor in successfully conceiving healthy children. In addition to nutrition, other steps such as weight control, supplemental intake, safety measures, and regular exercise are also among the important factors involved in a successful pregnancy period. Therefore, we could recommend several steps to be taken before pregnancy [1,2,3]:
- Adjusting to normal weight before pregnancy. So, if the woman is 20% above the desirable weight, she should gradually lose weight to reach her desirable (normal) weight before conception. And if she is 10% below the normal weight she should gradually gain weight before conception.

- Exercise: Being in good physical shape is good for both the mother and the baby. Therefore, it is recommended that the woman is in good physical shape before pregnancy. This could be achieved by some low impact sport like walking, cycling, or swimming at least three days a week.

- Safety: Any smoking or alcohol consumption should be stopped before pregnancy.  Any medication that is not approved by the consulting physician must be stopped as well.

- Certain improvements in the diet are strongly recommended. The literature suggests that if the woman is on any pills, she should stop taking the pills for more than 3 months if she wants to conceive, Since being on pills causes a decrease in folic acid and B6.

- Supplements : It is important to start on vitamins and mineral supplements. Literature suggests taking multivitamins and minerals that contain 100 to 200% or the daily value for all vitamins and minerals. In addition, daily intake of 400 mcg folic acid and 18 mg of iron is recommended as well. Studies have shown that taking daily multivitamins will result in :
48% reduction in neural-tube defects
39% drop in CV defects
47% lower rate of limb deformities
58% reduction in cases of cleft palate
52% decrease in urinary tract defects
63% drop in hydrocephalus    


     Daily intake of pre-natal multivitamins are recommended to all women of reproductive age, because studies have shown that more than half of all pregnancies are unplanned and almost all of birth defects happen early in pregnancy and during the 1st trimester. There is also a strong correlation between folic acid deficiency and neural tube defects. It is important to notice that folic acid supplementation is only effective before conception and during the first four weeks of pregnancy. Here is a list of special nutritional needs of pregnancy [1,3] :    
Folic Acid : As mentioned above, it decreases the frequency of neural tube defects and in that respect, for it to be effective it should be taken before conception and during the 1st four weeks of pregnancy. Recommended daily intake is 400-800mg. Women with previous child with defect should take 4mg/day starting 4 weeks before conception and continue during the 1st trimester. Certain medications like antibiotics can also cause deficiency in folic acid [1,3,5].

Iron: Iron requirements doubles during pregnancy, however, caution should be given as women during pregnancy are able to absorb more iron than usual. Studies show that most women enter pregnancy with low iron, and therefore, it is important to take prenatal vitamins. It is also recommended to take iron with vitamin C to help with digestive problems and away from calcium and magnesium, as it may cause constipation. Considering the fact that it takes 3 months for iron storage to build up, it is recommended to start taking it before conception. Women who are deficient in iron should start by taking 60-120mg/day and then decrease the amount to 30-60mg by the 20th week into the pregnancy. Deficiencies in iron could cause anemia in babies, as the fetus draws the iron from the mom. Studies have also suggested that there might be a link between pica and iron deficiencies. There is also indication that babies born to moms with good iron levels had superior language and motor skills. Among good sources of iron and the amount of iron they provide are [1,3,5]:
             ½ cup of firm tofu – 13.2mg
             1 cup of baked beans – 5mg
             3 oz of lean meat – 2mg
-  Calories: Optimal calorie intake per day in pregnancy and in particular during the last 2 trimesters should be 2000-2500 cal/day, which should be increased in lactating women to about 3000. Women who exercise should take an extra 300 cal/day [3,5].

-  Protein: Protein is very important as it forms the structural basis for all new cells and tissues, not just for the baby, but also the breast tissues in the mother. Recommended daily intake of protein is 80g/day. Issues related to protein deficiency are reduced placental growth, growth of baby and normal brain development. The research on high protein intake during pregnancy is not very clear, but there are suggestions of possible premature delivery [1,3,5].    

-  Fats: Fats are important in the development of the nervous system, in particular, omega FAs. Fats also help in the absorption of the fat soluble vitamins A, D, E, and K. Fat intake not be more than 25-30% of the total calorie intake [3,5].
-  Essential Fatty Acids (EFAs) : EFAs are in prevention of hypertension. Furthermore, omega 3 has been shown to be important in the vision and brain development, especially in the 3rd trimester and lactation. EFAs are also associated with improved cognitive function, visual acuity and effective infant growth and development [4].  
- Calcium: The baby will draw the calcium from the mother (at her expense). Calcium is needed for the mineralization of fetal skeleton and teeth. The recommended daily intake for calcium is 1000-2000 mg/day. Studies have shown that calcium supplements after the 20th week decreased the risk of pregnancy induced hypertension. Sources of calcium are milk and fortified soy milk. It has also been suggested that about half of moms and 1/3 of their babies are deficient in vitamin D. The recommended daily intake of vitamin D is 800-1000 IU. 
-  Vitamins A, C, E, K, B1, B2, B3, B6: Studies don’t show any particular symptoms associated with deficiencies in vitamins A,C,E, and K. Vitamins are important for the immune system, cellular differentiation, and vision. Low vitamin C may be associated with premature rupture of the membranes and premature birth. Recommended daily intake of vitamin C is 70mg. There is also no clear evidence of any problems due to deficiency of vitamins B1,B2, and B3. However, significantly lower APGAR score has been associated with vitamin B6 deficiency.
Zinc: Zinc deficiency has been associated with  malformation rates and other pregnancy outcomes. The recommended daily amount of zinc is 15mg for those with normal weight, and 25mg for underweight moms. Good sources for zinc are meats, leafy greens, and oysters.    
- Probiotics: It’s important in the development of the immune system. Babies get the first flora during birth. Mothers whose babies don’t get the normal flora are at higher risk of allergies in C-section babies.       
     Another important issue during pregnancy is the weight gain. Studies show that the average birth weight in the U.S. to be 7lbs and 6oz (3.35 kg), which usually results if the mother has gained about 24lbs (10.8 kg). Birth weight has been linked to later intelligence scores, and babies who have the average weight (mentioned above) have the lowest rate of infant illness, disability and death rate. It is important to notice that if someone is overweight, diet program and weight loss should be done before pregnancy and not during it. Therefore, the following recommendations are made for mothers who are either over- or underweight. For underweight mother, a gain of 28-40lbs (12.7-18 kg) is recommended. Mothers with normal weight will gain 25-35lbs (11-15.8 kg) during pregnancy. And the suggested weight gain for overweight mothers is 15-25lbs (6.8-11 kg). Mothers should lose about 15lbs (6.8 kg) after delivery within a few days if nursing, and about 25lbs (11 kg) by 6 weeks if nursing. If the baby is being bottle fed, by the 6th week after delivery the weight loss should be around 21lbs (9.5 kg). Therefore, mothers will lose weight faster if they breast feed their babies [1,2,3,5].
Furthermore, studies indicate that underweight women are at higher risk of  premature delivery, low birth weight, intrauterine growth retardation, placenta previa/abruptio, and delayed neurological development and decreased IQ. Women who are more than 20% above the normal body weight are at the risk of hypertension, gestational diabetes, prolonged labour, breastfeeding difficulties, difficult deliveries and C-sections, and future obesity. The normal weight gain during pregnancy should be as follows [3]:       
1st Trimester
     Gain 2-5lbs (0.9-2.2 kg) (if the gain is less than expected [poor growth] then it may result in SGA, or small for                gestational age        infants.
2nd Trimester
     ¾ to 1lbs/week (0.3-0.45 kg) ( poor growth may result in diabetes, heart disease, and hypertension later in life)
3rd Trimester
     ¾ to 1lbs/week (poor growth may result in impaired thymus, which is important in growth of immune system
     There are certain diseases that have been linked to birth weight. Among these diseases are:
Diseases linked to birth weight under 5.5lbs:
     Type II diabetes
     Impaired neurodevelopment
Other diseases that are thought to be associated with low birth weight, but are not widely accepted are:
     Chronic lung disease
     Behavioural problems
     Fingerprint patterns and left-handedness
     Precocious puberty and menarche
     Breast cancer
Disease that are linked to a birth weight of 10lbs or higher are:
     Breast cancer
     Polycystic ovary disease
     Prostate cancer
     Testicular cancer
     Childhood leukemia
Malnutrition before and during pregnancy has been greatly associated with the causes of fetal growth restriction and low birth weight. Other possible cause may be underweight mother (<50kg), gestational weight gain of more than 7kg, chronic infections, smoking, alcohol, genetics, diabetes, etc [1,3].
Safety before and during pregnancy is another important factor in nutrition. In particular [1,3]:
Smoking: This is the single most factor in determining intrauterine growth retardation. Elimination of smoking decreases 10% of infant mortality and about 25% in low birth weights. Smoking also negatively effects oxygen distribution to the fetus, may decrease nutrients to the fetus, and hinder woman’s weight gain. Smoking is also associated with bleeding during pregnancy, placenta abruptio & previa, premature rupture of membranes, and preterm delivery. Some studies also link smoking to increased sudden infant death syndrome (SIDS), and infants with increased respiratory illness.

Alcohol: Elimination of alcohol could result in 5000 fewer cases of fetal alcohol syndrome and about 50,000 fewer alcohol effected infants. Alcohol effects on babies in chronic alcoholics may be anomalies in the eyes, nose, heart, or CNS; growth retardation; small head circumference; mental retardation; increased rate of prenatal mortality; poor weight gain and failure to thrive. All of these conditions are encompassed in fetal alcohol syndrome, which effects about 2/1000 live births in the U.S. Fetal alcohol effects may also be causes by moderate drinkers, as well as deficiencies in folic acid, magnesium, and zinc. Studies have also shown that two or more drinks per day may increase the risk of physical and developmental abnormalities. There are no studies, which suggest that there might be any level of alcohol that might be considered safe during pregnancy.
Caffeine: Studies have shown that consumption of more than 300mg of caffeine daily may cause fetal growth retardation, miscarriage, and low birth weight babies. Among the side effects for women are nervousness, difficulty sleeping, and increased urination.
Nutritional suggestions could also be made for specific conditions that women encounter during pregnancy. Among these conditions are [1,3]:    
Morning Sickness: This is experienced by about 2/3 of women and it is actually considered a good sign of pregnancy. Women with this condition  experience fewer physical complaints, have decreased risk of miscarriage, and decreased physical malformations. To prevent this condition, the glucose levels should remain normal throughout the day. A number of suggestions could help in that regard:
     Drink liquids between and at meals
     Eat before getting out of the bed
     Eat frequently and in small amounts
     No fried foods, coffee, beer, beans, broccoli, onions
     Bedtime glucose and honey or protein
     Foods rich in B6 and supplements (50-100mg/day)
     Ginger root (anti nausea) 3-4 capsules/day
Constipation: This is mostly caused by hormones and diet and can lead to hemorrhoids and varicose veins. To treat constipation, the following steps could be taken:
     Consumption of foods reach in fiber to absorb more water
     Avoid drinking coffee, but drink more of other fluids
     Exercise regularly
     Eat prunes or prune juice, kiwi, ground flax seed
     Decrease meat
     Use footstool during bowel movement
     Take 1-2 table spoon of molasses in warm water, twice a day
Vomiting: To help with persistent vomiting, women should take lemonade and dry ginger ale, effervescent drinks, small frequent snacks
Heartburn and Indigestion: This is mostly caused by hormones that soften sphincter in the stomach. To treat this the following steps could be taken:
     Avoid hot drinks
     Drink 30 mins before and 1 hour after small meals
     Try to sit and relax when eating and make sure to chew well
     Avoid fats, fried, and spicy foods
     Don’t use antacids as it may be harmful to the baby
     Try using calcium which is a natural antacid
     Chewing gum stimulates saliva and helps in neutralizing acids
Leg Craps: It is not clear what is the exact cause of this condition, but the following steps may be helpful in treating it:
     Use massage, warm compresses and stretch
     Increase calcium intake and avoid phosphate
     Try to do calf stretches before going to bed
Breastfeeding: This is something that is highly recommended to be done for at least 6 months to one year. Benefits of breastfeeding are:
     Protection from infectious diseases and allergies
     It’s easier to digest
     It has lower protein and mineral content, so the kidneys have to work less
     Iron is more easily absorbed
     Components are more bio-available compared to formula, like calcium and zinc
     Babies grow more rapidly in the first 3 months and less rapidly form 3 to 12 months when compared to babies            fed with formula
     It is important to avoid drugs as everything appears in the breast milk
Edema: To treat swellings, especially around ankles, women should take nettle tea, drink water, take lymphatic massage and supplement with B6 (100mg/day)

Anemia: To treat anemia women could increase the intake of vitamin C, which will cause an increase in the absorption of iron; black strap molasses (1/2 tea spoon, 4x/day); red raspberry tea, and homeopathic solutions like ferum phosporica

Insomnia: Insomnia could be treated by doing regular exercise, consumption of chamomile tea, supplement with calcium (250-500mg 20 minutes before bed)
Certain nutritional suggestions, as mentioned above, are useful in the preparation for birth. Mother’s cordial helps in preparing uterus and cervix for birth. Red raspberry tea is helpful in tuning uterine muscles, easing with the morning sickness, and help with effective contractions for birth. Nettle tea is helpful in easing leg cramps and reduction in edema and hemorrhoids. Perineal massages are helpful in stretching the tissues for birth and increasing the blood flow so healing process is faster [2,3].
Specific nutritional recommendations for labour, birth, after birth are as follows [3]:    
- ARNICA 200 CH helps to decrease bruising and edema after the birth
- CAULOPHYLLUM 200 CH or Blue Cohosh helps to soften cervix for dilation and is helpful in speeding up the delivery. It should be give in single dose once the water breaks
- Pulsatilla 200 CH may be helpful in breech position and when the labour stops and starts frequently
Postpartum nutritional recommendations include perineal tears like st. john’s wort, which kills nerve pain. To promote lactation, suggested recommendations are hops tea, beer (1/2 pint/day), blessed thistle tea, anise, and nettles [3].
In conclusion, the following advice and recommendations could be given for the preconception, fetal period, and neonatal period [1,3]:
- Preconception
     At least 80g/day of protein
     Fruits and vegetables (8-10 servings/day)
     Cessation of smoking and complete stop or maximum of one glass of wine, in term of alcohol consumption
     Vitamins and minerals to be taken at least 6 months before conception:
          Multivitamins and minerals
          Folid acid – 600-800 mcg/day
          Vitamin B12 – 20 ug/day
          Vitamin D – 1000 IU/day
          Vitamin C – 500 mg/day
          Vitamin E – 100 mg/day
          Calcium – 1200  mg/day
          Magnesium – 300 mg elemental/day
- Fetal period
     At least 80g/day of protein
     Fruits and vegetables (8-10 servings/day)
     Cessation of smoking and alcohol consumption
     Vitamins and minerals
          Multivitamins and minerals
          Folic acid 600-800 mcg/day
          Vitamin B12 – 20 ug/day
          Vitamin D - 1000 IU/day
          Vitamin C - 200 mg/day
          Vitamin E - 50 mg/day
          Calcium - 1200 mg/day
          Magnesium – 300 mg elemental/day
          Probiotic – min 8 billion/day
- Neonatal period
     In breastfeeding (minimum of 3 months and reduced up to one year)
          At least 80g/day of protein
          Fruits and vegetables (8-10 servings/day)
          No smoking, preferably no alcohol, or maximum of one glass of wine per day
          Multivitamins and minerals
               Folic acid – 600-800 mcg/day
               Vitamin B12 – 20 ug/day
               Vitamin D – 1000 IU/day
               Vitamin C – 200 mg/day
               Vitamin E – 50 mg/day
               DHA minimum of 2400mg/day for 4 months
               Calcium – 1200 mg elemental/day
               Magnesium – 300 mg elemental/day
               Probiotic minimum of 8 billion/day
               probiotic to neonate minimum of 2 billion/day
1) Somer E, Nutrition for a healthy pregnancy. 2nd ed. New York: Henry Holt and Company Publishers; 2002.
2)  Lammi-Keefe CJ, Couch SC, Philipson EH, Handbook of Nutrition and Pregnancy. Totowa: Humana Press; 2008.
3)  Schoales D, Female Care. 2010-2011.
4)  Niinivirta K, Isolauri E, Laakso P, Linderborg K, Laitinen K, Dietary Counseling to Improve Fat Quality during Pregnancy Alters Maternal Fat Intake and Infant Essential Fatty Acid Status. The Journal of Nutrition, May 2011;1281-1285.
5)   Barnard ND, Eating for two? Vegetarian Times, June 2011;30-31.