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NUTRITION IN PREGNANCY AND LACTATION A REPORT TO THE CHILDREN'S BUREAU BY THE COMMITTEE ON MATERNAL NUTRITION FOOD AND NUTRITION BOARD NATIONAL ACADEMY OF SCIENCES-NATIONAL RESEARCH COUNCIL FOR TRANSMITTAL TO THE aHILDREN*S>SUREAU, 1967

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TABLE OF CONTENTS Page PREFACE ................ i CHAPTER I. THE ROLE OF NUTRITION IN REPRODUCTIVE EFFICIENCY 1 Definitions of Diet and Nutrition .... 5 II. RECOMMENDED NUTRIENT ALLOWANCES FOR PREGNANCY AND LACTATION 7 Calories 10 Protein 13 Calcium 17 Iron 20 Ascorbic Acid (Vitamin C) 22 Vitamin A 22 Vitamin D 22 Thiamine 26 Riboflavin 26 Niacin 27 Folacin (Folic Acid) 27 III. CRITERIA FOR THE ASSESSMENT OF NUTRITIONAL STATUS IN PREGNANCY 28 IV. SPECIAL PROBLEMS 34 Weight in Pregnancy 34

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Maternal Nutrition and Toxemia of Pregnancy. . 38 Muscle Cramps 43 Vitamin and Mineral Supplementation .... 43 Anemia in Pregnancy 45 Hyperemesis 47 BIBLIOGRAPHY - 50 APPENDIX ................ 53

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PREFACE The Committee on Maternal Nutrition of the Food and Nutrition Board of the National Research Council was appointed in 1966 with the purpose of reviewing and interpreting the cur- rent state of knowledge of the relationships between nutrition in pregnancy and the outcome of pregnancy for mother and infant. Such an undertaking is particularly pertinent at this time in the United States since public health statistics indicate that neonatal and infant mortality experience in this country has not been as favorable in the most recent two decades as in some countries of Western Europe. The Children's Bureau of the Department of Health, Education, and Welfare has developed new programs in maternal and infant care and services for "Children and Youth" to which nutrition services must contribute. There- fore, the Committee accepted as its first responsibility the development of a report based on current nutrition concepts which may serve as a basis for the development of authoritative guidelines for the nutrition component of maternal and child health programs. This report has been prepared without the advantage of a complete review and synthesis of the world

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literature on the subject, a task to be undertaken by the Committee in a later monograph. This report represents the views of the Committee drawn from its experience in the fields of o.bstetrics, pediatrics, and nutrition. It is submitted to the Children's Bureau with the hope that it may assist the staff of that agency in develop- ing nutrition service in its programs concerned with maternal and infant health. The Committee considers the recommendations contained in this report as tentative and anticipates that cer- tain of these will be modified when a more detailed evaluation of the world literature is made. An eventual objective of the Committee is to designate fields of research which should receive increased attention in order to gain the knowledge necessary to make nutrition service more fully effective in the management of pregnancy, thus offering the greatest opportunity to the new-born for health, without impediment to physical and mental development. ii

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CHAPTER I • THE ROLE OF NUTRITION IN REPRODUCTIVE EFFICIENCY Reproductive efficiency is a term referring to all aspects of the process and outcome of pregnancy in a quali- tative sense. It means productivity without waste. In the United States the majority of babies are born healthy and at full term to healthy young women after normal pregnancies. There is a high degree of reproductive efficiency among women who themselves were born and reared in an environment which favored normal growth and development and provided for their nutritional, emotional, and educational needs. The children of families in these favorable environ- ments have adequate diets, develop good eating and health habits which carry over into their adult lives, have few serious illnesses, obtain good medical care, have a good education, tend to marry and bear and rear their children under under similar favorable conditions. Good health and nutrition favor growth and development to full genetic potential. In general the resultant tallness is accompanied by a high level of biological efficiency and is associated with successful 1

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reproductive performance. There are, however, many women in the United States whose pregnancies are complicated or tend to repeatedly result in weak, poorly developed, or defective infants unable to survive the full term of pregnancy or the first days after birth. Fetal and neonatal death rates, the incidence of prematurity, low birth weight, and congenital defects are measures of reproductive inefficiency. This pregnancy wastage is great. Each year in this country at least 65,000 babies die during the last half of pregnancy. Of the approximately four million born alive, 67,000 fail to survive as long as one week. In a large pro- portion of deaths occurring in the first month, a contributing factor is low birth weight. Of the approximately 350,000 small, weak, and premature infants born each year, there are many whose survival depends upon special skilled care after birth, and many of the survivors continue to have health problems and retarded physical and mental development. Nearly 250,000 babies are born annually with congenital malformations. It is neces- sary to consider, in addition to infant morbidity and mortality, the maternal depletion and ill health which may be produced because of pregnancy. Eight developed countries currently report significantly lower late fetal and neonatal mortality rates than does the

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United States, indicating that our losses are needlessly high, and our recent rate of improvement is the smallest of any com- parable country. Possible reasons may be the increase in the proportion of births to low income, non-white families in large city public hospitals; the increased incidence of low birth-weight infants; and a slow rate of decline in mortality rates among non-white infants. The women whose pregnancies contribute most to these poor pregnancy outcomes have characteristics opposite to those of reproductively efficient women. They tend to be women of lower family income who have grown up in large families with inadequate means to provide good medical care, education, and nutrition. During pregnancy, these women have more chronic illnesses, more nutritional deficits, and more obstetrical complications. Toxemia of pregnancy is one of the most preva- lent of these complications. Although a number of factors have been implicated in toxemia, an important one may be poor nutrition. In the United States, reproductively inefficient women are likely to be of Negro, American Indian, or Spanish American origin, ethnic groups which make up a substantial proportion of the lower socio-economic strata. But also included are many women who have not grown up in poverty who, for various reasons, arrive at childbearing age with poor health habits and with associated health, nutritional, and

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emotional disorders. In all sectors of our society, the trend toward extreme slenderness, food fads, the tensions felt by the young in our society, and childbearing at a very early age are factors that may have an adverse effect on reproductive efficiency. How such factors affect the course and outcome of pregnancy is not yet clear. Research efforts to identify individual causes have encountered great difficulty because many factors tend to cluster in the same women. Nevertheless, there can be little doubt that good nutrition plays an essential role in the healthy growth and development of the mother from the time of her own conception, preparing her for successful childbearinq.