2.0 Antenatal nutrition - Home | Queensland Health HEALTHY START IN LIFE ANTENATAL NUTRITION 1 2.0 Antenatal nutrition 2.1 Nutrition during pregnancy (1,2,3,4,5) Nutritious foods and

1A HEALTHY START IN LIFE ANTENATALNUTRITION

2.0 Antenatal nutrition2.1 Nutrition during pregnancy (1,2,3,4,5)Nutritiousfoodsandanactivelifestylecanhelpachieveoptimalhealththroughoutlife.Goodnutritionisimportantatallstagesthroughoutlifeandparticularlyduringpregnancy.Thehealthandnutritionalstatusofmothersandchildrenareintimatelylinked(1).

Beginningpregnancywithahealthydietisgivingthebabythebestpossiblenutritionaladvantage.Awidevarieddietisvitalinsupportingthegrowthanddevelopmentofthefoetusandthemaintenanceofthewoman’sownhealth.Nutritionalrequirementsformostnutrientsincreaseduringpregnancy,particularlyfolate,iron,zincandvitaminC(2).Thereisonlyasmallriseinenergyrequirements,whichcanbeachievedbyeatingforexampleanextra2–3slicesofbreadperday(3).

Table 5 Foodrecommendationsduringpregnancy

Food group Number of serves 1 serveBread, cereal , rice, pasta, noodles

4 – 6

2slicesbread1mediumbreadroll1cupcookedrice,pastaornoodles1cupbreakfastcerealflakesorporridge½cupmuesli

Fruit

4

1piecemediumsizedfruit2piecessmallerfruit8strawberries20grapesorcherries½cupjuice1cupdiced/cannedfruit1½Tbspsultanas

Vegetables, legumes

5 – 6

1mediumpotato/yam½mediumsweetpotato1cuplettuceorsaladvegetables½cookedvegetables

Meat, fish, poultry, eggs, nuts and legumes

1½

65–100gcookedmeat/chicken80–120gcookedfish2smalleggs1/2 cupcookeddriedbeans,lentils,chickpeas,splitpeasorcannedbeans1/3cuppeanuts/almonds

Dairy

2

1cupmilk40g(2slices)cheese200gyoghurt1cupcustard

Extra foods0 – 2½

1Tbspmargarineoroil1cansoftdrink½smallchocolatebar4plainsweetbiscuits

Adaptedfromthe Australian Guide to Healthy Eating

2 A HEALTHY START IN LIFE ANTENATALNUTRITION

2.2 Sample meal planThe following examples illustrate how the Australian Guide to Healthy Eating can be incorporated into a daily meal plan to meet minimum nutritional requirements.

Breakfast

1cupbreakfastcerealflakes/1cupporridge

Milk(250ml)

1cupstrawberries/1freshorange/½grapefruit

Morning tea

2ricecakes/1slicetoastwith1slicecheeseandtomato

Lunch

Salmon/eggortuna/andsaladbreadroll

1piecefreshfruit

Afternoon tea

1scone

½cupfruitjuice

Dinner

1smallsteak(100g)withmixedvegetables(total1½cups)

1smallpotato

1cupfruitsaladwith2Tbspyoghurt

Supper

2slicesraisintoast,scrapemargarine

Parenthandoutsavailableat

qheps.health.qld.gov.au/ahwac/content/home_nemo.htm


Folate during pregnancyFolateisaBgroupvitaminneededforhealthygrowthanddevelopment.Itsrequirementsareincreasedduringpregnancyfornormalgrowthoftheunbornbaby.Adequatefolateintakehelpstopreventneuraltubedefectsinthebaby,suchasspinabifida(2).

Thevitaminisknownasfolatewhenitisfoundnaturallyinfoodandasfolicacidwhenitisaddedtofoodorusedindietarysupplements(4).

Therecommendedintakeofdietaryfolateforpregnantwomenis600µg/daythroughoutpregnancy.However,toreducethelikelihoodofneuraltubedefectsinthebaby,itisrecommendedthatwomenconsumeanadditional400µg/dayfolicacidthroughasupplementorintheformoffortifiedfoodsforatleast1monthbeforeand3monthsafterconceptioninadditiontoconsumingfoodfolatefromavarieddiet(2).

Itisdifficulttogetenoughfolatefromnaturalsourcesalonetoreducetheriskofneuraltubedefectsinpregnancy.Folicacidsupplementsareavailableoverthecounter.Womenwhohaveafamilyhistoryofneuraltubedefectslikespinabifidarequiremedicaladvicebeforebecomingpregnant(4)astheymayneedevenhigheramountsoffolicacid.

Goodsourcesoffolateincludeleafyvegetables,wholegrains,fortifiedcereals,peas,nuts,avocadosandyeastextracts(egMarmite, Promite, Vegemite etc).

Forfurtherinformationandparenthandouts:

www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm

Checkdiet contains rich sources of folate before and during pregnancy✔✔

advise women to take folate supplements for 1 month before conception ✔✔and during the first trimester of pregnancy

if dietary intake is poor, consider continuing folate supplement after ✔✔the first trimester

folic acid intakes should not exceed 800 – 1000 µg/day.✔✔


Iron during pregnancyIronisacomponentofhaemoglobin,thecomponentofbloodwhichcarriesoxygenaroundthebody.Thepeakironrequirementinpregnancyoccursthroughoutthesecondandthirdtrimesters.Thisistosupporttheexpansionofthematernalredbloodcellmass,thegrowingfoetusandtheplacenta.Alackofironmayresultinanaemia.Womenwhosedietpriortopregnancywaslowiniron,mayhavelowironstores.Thisincreasestheirriskofdevelopingirondeficiencyanaemiaduringpregnancy.Dietaryironisusedbythegrowingbabyfirst,leavingthemother’sstoresdepletedifherintakeisinadequate.Lowironlevelsinearlypregnancyhavebeenlinkedtoprematurebirthandlowbirthweight.

TheRDIforironinpregnancyis27mg/day(5).Amixeddietofanimalandplantfoodscanhelpyouachieveyourironintake.AbsorptionofironisbetterfromanimalfoodscomparedtoplantsourcesandtherecommendeddietaryintakesarebasedonamixedWesterndiet.

Therearetwotypesofironinfood:ironfromanimalfoods(calledhaemiron)andironfromplantfoods(callednon-haemiron).

Haemironistakenupbythebodyabout10timesbetterthannon-haemiron.Meatsarethebestsourceofiron.Theredderthemeat,thehigheritisiniron.Thismeansbeefandlambarehigherinironthanpork,chickenorfish.Colouredfleshfish,suchastunaandmulletarehigherinironthanreeffish,suchasbarramundi.

Non-haemironisfoundinsomeplantfoodssuchas:

wholegrainandironfortifiedbreadsandcerealsfoods,eg.breakfastcereal✔■

withaddediron

legumes,eg.kidneybeans,bakedbeans✔■

greenleafyvegetables,eg.spinachandbroccoli✔■

nutsanddriedfruit.✔■

Rememberthatironfromthesefoodsisnottakenupbythebodyaswellasironfromanimalfoods.Youwillneedtoeatmoreofthesefoodsiftheyareyouronlyironsource.

AddingaglassoffruitjuiceorotherfoodsrichinvitaminC(suchastomato,broccoliorcapsicum)toamealwillincreasetheamountofironthebodyabsorbs.Incontrast,tea,coffeeandunprocessedbrancaninhibitironabsorption.

Indicators of iron deficiency

Ironstatusisdeterminedbymeasuringbloodlevelsofhaemoglobin,serumferritinandserumtransferrin.Serumferritinisthebestindicatorofironstores.Lowserumferritinlevelsindicatedepletedironstores.Haemoglobinisnotasensitiveindicatorofironstatus,withlevelsdecreasingoftenonlywhenferritinstoresareseverelydepleted.Inaddition,haemoglobinlevelsdecreaseduringthethirdtrimesterofpregnancyduetohaemodilutioneffects.Ferritinlevelsremainunchangedduringthistime.Serumtransferrintransportsironintheblood.Transferrinvaluesincreasewithirondeficiencyanddecreasewithironoverload.Ironintakeshouldbeincreasedwhenserumferritinlevelsarelow.Ideallythedietshouldbeexaminedforadequateironintake.Ifthedietappearstoprovideadequateirondespitelowferritinlevels,supplementsmaybeconsidered.


Checkif serum ferritin levels are low, iron intake needs to be increased✔✔

iron supplements may cause constipation. Constipation may be minimised ✔✔by consuming adequate intakes of dietary fibre and fluid. Foods from the meat/meat alternatives group provide the best sources of iron. Vegetarians need to consume vitamin C rich foods with meals to increase iron vabsorption and eat a good variety of non-haem iron sources.

IodineTheRDIforiodineinpregnancyis220ug/day(5).Iodinedeficiencyinpregnancycanaffectgrowthanddevelopmentintheunbornchild,increasethechanceofmiscarriageandhaveseriousimplicationsforintellectualdevelopment.Iodinecanbefoundindairyproductsiemilkandyoghurt,breadbakedwithiodisedsaltandsaltwaterfish.Itisveryimportantformotherstoconsumesufficientiodinefromthetimeofconception,justasitisforthemorewell-knownnutrientsofironandfolate(5).

Multivitamin supplementsApartfromtherecommendedfolatesupplement,itisbesttoobtainnutrientsfromahealthydiet.MultivitaminsnotdesignedforpregnancyarenotrecommendedastherearedangersassociatedwithexcessivedosesofnutrientssuchasVitaminsA,DandB6(2).

Alternative and herbal remediesMostherbalandhomeopathicremedieshavenotbeentestedtodeterminetheirsafetyduringpregnancy.Manyherbalpreparationshaveadrug-likeeffectandshouldbeusedwiththesamecautionaswithotherdrugsduringpregnancy.Herbalpreparationsshouldbeavoidedduringthefirsttrimester.TheNationalPrescribingService(NPS)Medicineslinecanprovideinformationregardingalternativetreatmentsinpregnancy,phone1300888763.

Patienthandoutsavailableat

qheps.health.qld.gov.au/ahwac/content/home_nemo.htm


2.3 Special considerations during pregnancyListeriaListeriaarebacteriacarriedinsomefoodsthatcancauseaninfectioncalledlisteriosis.Thebacteriacommonlyinhabitsoil,water,plantsandsewerage.Theinfectionmaycausefewornosymptomsinhealthypeople,includingpregnantwomen.However,theriskoftransmissionfromtheinfectedpregnantwomantoherunbornchildishigher.Infectionofthefoetuscanleadtomiscarriage,stillbirth,prematurebirthorsevereillnessinnewbornbabies(2).

Thebestwaystoavoidlisteriainfectionsincludehygienicpreparation,storingandhandlingoffood.Foodsshouldbeeatenfresh,orthoroughlycooked,orwellwashedifeatenraw(fruitandvegetables).Leftoverscanbeeateniftheyhavebeenrefrigeratedimmediatelyandstoredforlessthan24hours.

Thefoodsmostlikelytocarrythebacteria,increasetheriskofinfectionandthereforeshouldbeavoided,include:

softandsemisoftcheeses,eg.brie,camembert,ricotta,blue,fetta✔■

softserveicecream✔■

unpasteuriseddairyproducts✔■

pate✔■

chilledseafood✔■

salads-fruit/vegetable,eg.prepared,prepackaged,smorgasbord/saladbars✔■

coldmeats,includingchicken,eg.deli,sandwichbars,andpackagedready-to-eat.✔■

Healthy tips

always wash hands before preparing or serving food and after handling ✔✔animals or visiting the toilet

animals can carry the toxoplasmosis parasite which can cause disease in ✔✔humans so keep them out of the kitchen; avoid touching faeces and wear rubber gloves under garden gloves

wash cookware and utensils well after use ✔✔

store raw foods down low in the fridge and check fridge temperature ✔✔regularly

foods and leftovers that belong in the fridge should always be refrigerated ✔✔as soon as possible

thaw frozen meats in the fridge ✔✔

once cooked, pasta and rice should be stored in the fridge ✔✔

look for ‘best before’ and ‘use by’ dates on packaged foods.✔✔

Forfurtherinformation:



MercuryFishisasafeandimportantpartoftheAustraliandiet.Itcontainsanexcellentsourceofprotein,islowinsaturatedfat,highinomega3fishoilsandisanexcellentsourceofiodine.Therehasbeensomeconcernregardingthelevelofmercuryinfish,specificallyaccumulationofmercuryinfishthatarehigherupthefoodchain.

Food Standards Australia and New Zealand(FSANZ)advisespregnantwomen,andwomenplanningpregnancy,toeatavarietyoffishaspartofahealthydiet.However,pregnantwomenshouldlimittheirintakeofcertaintypesoffish.

Table 6. Recommendationsoffishconsumptionduringpregnancy

Pregnantwomenandwomenplanningpregnancy(1serve=150g)

1serveper fortnight ofshark(flake)orbillfish(swordfish/broadbillandmarlin)andNOotherfishthatfortnight

OR

1serveperweek oforangeroughy(deepseaperch)orcatfishandNOotherfishthatweek

OR

2–3servesperweekofanyotherfishandseafoodnotlistedabove

AdaptedfromFood Standards Australia and New Zealand

Forfurtherinformation:


CaffeineCaffeineisachemicalfoundinmanyfoodsanddrinks,includingcoffee,teaandcola.Itaffectsthenervoussystemandcancauseirritability,nervousnessandsleeplessness.Duringpregnancyittakeslongertobreakdowncaffeine.

Whilehavinglargeamountsofcaffeinedoesnotappeartocausebirthdefects,drinkinghighamountsofcaffeinemaymakeitmoredifficulttobecomepregnantandmayincreasetheriskofmiscarriage.

Itisbesttolimitthedailyamountofcaffeineto:

2cupsofcoffee,or✔■

4cupsoftea,or✔■

4cupsofcoladrink,or✔■

lessthan1cupofcolaorenergydrinksthatcontainextracaffeine,or✔■

decaffeinatedvarietiesareanoptionwhichcontainslittlecaffeinehoweversafelevelsof✔■

decaffeinatedproductsforpregnantwomenareunknown.

(ReproducedwiththepermissionofCommonwealthDepartmentofHealthandAgeing)

Artificial sweetenersTheuseofonlysomeartificialsweetenersisconsideredtobesafeduringpregnancy.FSANZhaslistedaspartame(marketedinfoodproductsasEqual, Hermesetas and Nutrasweet)andsucralose(Splenda)assafetouseduringpregnancy(2).


AlcoholDuringpregnancyalcoholcrossestheplacentaandcanleadtophysical,growthandmentalproblemsinsomebabies.Babiesaffectedbyalcoholtendtohavelowbirthweights.Theymayalsohavephysicalandbehaviourproblemsatbirthandthroughoutchildhood.(2)

Therearenoknownsafelevelsofalcoholconsumptioninpregnancy.Therefore,itisbesttoavoiddrinkingalcoholduringpregnancyasmuchaspossible.

The Australian National Health and Medical Research Council (NHMRC) has made the following recommendations for women who are pregnant or planning a pregnancy:

Women may consider not drinking alcohol at all

It is most important not to become intoxicated

Women who choose to drink should have less than 7 standard drinks per week

Women should have at least 2 alcohol free days a week

On any 1 day no more than 2 standard drinks should be consumed. These drinks should be spread over at least 2 hours.

Drinkinglargerquantitiesatanyonetimemayaffectthedevelopingfoetalbrain.

1standarddrinkisequalto:✔■

100mlwine✔■

1‘pot’ofbeer(285ml)✔■

1can/stubbie(375ml)lowalcoholbeer✔■

1nipofspirits(30ml)✔■

60mlfortifiedwine(portorsherry).✔■

Checkalcohol consumption is reduced to nil where possible. If alcohol is consumed, ✔✔the intake should not exceed more than 2 standard drinks per day.

Morning sicknessMorningsicknessisacommonsymptomofearlypregnancyand,inmanycases,goesawaybytheendofthefirsttrimester.Itiscausedbychangesinhormonesduringpregnancyandmaymakeeatingdifficult.Althoughitiscalled‘morningsickness’,nausea(withorwithoutvomiting)canhappenatanytimeoftheday.Asmallnumberofwomenexperienceseverevomitingwhichcanleadtodehydrationandelectrolyteimbalances.Suchwomenrequiremedicalassistanceandpossiblyhospitaladmissionforcorrection.Inothercases,frequentandprolongednausea/vomitingcanleadtoaninadequateenergyintakewhichresultsinweightloss.Thisweightlossusuallyceasesoncenauseareducesandappetiteimproves.

Checkadequate energy intake to prevent weight loss✔✔

if morning sickness persists with vomiting more than twice daily for more ✔✔than 2 days, medical intervention should be sought as hospitalisation may be required. Ensure adequate fluid replacement to avoid dehydration.

Patienthandoutsavailableat

qheps.health.qld.gov.au/ahwac/content/nemo_review.htm

Thefollowingpagecanbeusedasaparenthandout.


Morning sickness

Morningsicknessdoesnotusuallycauseanyproblemsfortheunbornbaby.Somefoodandeatingsuggestionsthatmayhelpmanagesymptomsofmorningsicknessornauseainclude:

eatsmallermealsmoreoften.missingmealscanmakenauseaworse✔■

avoidlargedrinks.havefrequentsmalldrinksbetweenmeals✔■

limitfatty,spicyandfriedfoods✔■

foodhasastrongerodourorsmellwhenitisheated,whichmaymake✔■

nauseaworse.ifpossible,haveotherpeoplehelpwithcooking,orprepareyourfoodattimesofthedaywhenyoufeelbetter

tryeatingadrybiscuitbeforeyougetoutofbedinthemorning✔■

eatahealthysnackbeforeyougotobedatnight.thismightincludefruit✔■

(fresh,tinned,dried),crackerswithhardcheeseoryoghurt

avoidfoodsiftheirtaste,smellorappearancemakeyoufeelsick✔■

ifvomiting,itisimportanttodrinkenoughfluids.Itmaybeeasiertohave✔■

lotsofsmalldrinksthantotryanddrinkalargeamountinonego.Tryavarietyoffluidssuchaswater,fruitjuice,lemonadeandclearsoups.Sometimesitcanbehelpfultotrycrushedice,slushies,iceblocksorevensuckonfrozenfruitsuchasgrapesororangesegments.

Note: Thestomachacidsinvomitingcansoftenteethenamel.Itisbestnottouseatoothbrushtocleantheteethstraightaftervomitingasthismaydamagethem.Haveadrinkofwatertocleanyourmouth.


ConstipationConstipationiscommoninpregnancyforthefollowingreasons:

Intestinalmuscleappearstolosetone,makingitdifficultforfoodtopassthrough:✔■

thebabyinlatterpregnancy,placespressureontheintestine,exacerbatingtheproblem✔■

ironsupplementationmaycauseconstipationinsomewomen.✔■

Constipationcanbeminimisedbyensuring:adequateexercise✔■

highfibreintake✔■

adequatefluidintake(1.5–2Lperday).✔■

Checkensure adequate fibre intake by eating fruit, vegetables and wholemeal/✔✔wholegrain breads and cereals

ensure adequate fluid intake (ie. 1.5 l/day)✔✔

regular activity ✔✔

regular use of laxatives is not recommended.✔✔

Parenthandoutsavailableathttp://qheps.health.qld.gov.au/ahwac/content/nemo_review.htm

HeartburnHeartburnoccursforanumberofreasonsincluding:

Relaxationoftheoesophagealmusclesduringpregnancy(underhormonalinfluences)✔■

allowsacidtorunintotheoesophagus,andpressurefromthegrowingbabyonthestomachcausesabackflowofacid.Somesuggestionsforreliefofheartburninclude:

Eatsmallermealsfrequently✔■

Chewfoodwell✔■

Avoidfattyandspicyfoodswhichmayirritatethecondition✔■

Drinkfluidsseparatelytomeals✔■

Snackondrybiscuitsortoast✔■

Sippingmilkmayeaseheartburntemporarily✔■

Relaxwhileeating✔■

Avoidlyingdownorbendingoverdirectlyaftermeals✔■

Don’tsmoke✔■

Avoidalcohol✔■

Careneedstobetakentoensurenoneofthefoodgroupsareomittedfromthediet,✔■

sincethiscanreducethenutritionaladequacyofthediet

Someantacidsaresafetotakeduringpregnancy,butmayinhibitironabsorption.✔■

Recommenduseundermedicalsupervision.

Parenthandoutsavailable

qheps.health.qld.gov.au/ahwac/content/nemo_review.htmwww.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm


2.4 Weight gain during pregnancyAhealthyweightgainduringpregnancycanvarybetweenindividualsanddependsonpre-pregnantweight.Itisrecommendedwomenwhoareplanningapregnancyshouldattempttoreachahealthybodyweightbeforetheybecomepregnantasbeingoverweightorobese,orunderweight,priortoconceptionisassociatedwithanincreasedriskofanumberofcomplications.

Anaverageweightgainduringpregnancyforapersonofahealthyweightis10-15kg.ThebreakdownofthisweightgainisillustratedinTables7and8.Thematernalfatstoresareusedlaterintheproductionofbreastmilk.Healthyweightgainismostlyseeninthesecondandthirdtrimesters(afterthefirst3months)ofpregnancy.Thisisthetimeofpregnancywhenmother’senergy(kilojoule)requirementsincrease.However,itisbesttofocusonfoodqualityratherthanquantitytomeetthenutritionalneedsinpregnancy.Thereisnoreasontoincreasefoodquantitytothepointof‘eatingfortwo’asthisislikelytoleadtoextraweightgain.

Howeveritmustbestressedthatpregnancyisnotthetimeforweightlossdiets.Restrictingfoodandnutrientintakecompromisesboththedevelopmentofthebabyandthemother’snutritionalstatus.Womenwhoareunderweightorhavesomeformofeatingdisorderplacetheirbabyandthemselvesatnutritionalrisk.Ifthemothers’dietisinadequate,maternalstoreswillbedepleted.Thiscancompromisethemothers’health,sincethebabytakesthenutrientsitrequiresfirst.

TheInstituteofMedicine(IOM)recommendsweightgainrangesbasedonpre-pregnancybodymassindex(BMI)(8).Researchhasshownpregnancyweightgainwithintheserangesisassociatedwiththebestoutcomeforbothmothersandinfants.TocalculateBMIusethefollowingequationorrefertoFigure3.

BMI=w(kg)/ht(m)2

Figure 3 BodyMassIndexchart


Table 7 Recommendedtotalweightgainduringpregnancy,proportionaltoweightforheight

Weight-for-height category Recommended total gain (kg)

Low(BMI<19.8) 12.5-18

Normal(BMI19.8-26.0) 11.5-16

High(BMI>26-29.0) 7-11.5

Obese(BMI>29.0) >6.0

Table 8 Thegeneralguidetothepatternofweightgainduringpregnancy

Trimester Healthy weight Underweight Overweight Obese

1st 0-2 1-3 0-1 0-1

2nd 4-6 5-8 3-4 2-3

3rd 4-6 5-8 3-4 2-3

Total 11-16kg 12-18kg 7-11kg <7kg

Thepatternofweightgainvariesforeachwomanandeachpregnancy.Specificadviceforindividualneedsshouldbesoughtfromaqualifieddietitianorhealthprofessional.

Healthy eating to increase weight gain Sometimesifwomensufferfrommorningsicknessearlyinpregnancyitmaybedifficulttogainweightandsometimesmayloseasmallamount.Thisisnotcauseforconcernaslongasweightgainstartsinthesecondtrimesterofthepregnancy.

Inadequateweightgaininpregnancycanadverselyaffectthehealthofmotherandbaby.Ifnotgainingenoughweightsuggesttheseideas:

Eat3mealsaday✔■

Includesnacksbetweenmeals✔■

Enjoyhealthysnackfoodssuchas:✔■

Freshordriedfruit✔■

Yoghurt✔■

Nutsandseeds✔■

Mueslibars✔■

Biscuitsandcheese✔■

Milkdrinks✔■


Healthy eating to control weight gain Pregnancyisnotatimeforstrictdieting.However,excessiveweightgainduringpregnancycancauseproblemswithhighbloodpressure,gestationaldiabetesforthemother,alargeforgestationalagebabyanddeliverycomplications.Ifmotherisoverweightitisimportantcontrolweightgaininpregnancy.

Limit the amount of fat eaten

Limitintakeofbiscuitsandcakes✔■

Limitintakeofchipsandcrisps✔■

Reducetheamountoffatusedincooking✔■

Chooselowfatdairyproductsincludingmilk,yoghurt,andcheese✔■

Avoidcreamandsourcream✔■

Trimallthefatoffmeatbeforecooking✔■

Removetheskinfromchicken✔■

Limithighfattake-awayfoods✔■

Limit high sugar foods

Drinkwaternotsoftdrinkorcordial✔■

Use“diet”orlowjouleproducts✔■

Limitfruitjuicestoonceaday,thesearehighinsugar✔■

Limitchocolates,lolliesandsweets✔■

Limitintakeofdesserts✔■

Minimisesnacking✔■

Increasephysicalactivity✔■

Checkweight loss is not recommended during pregnancy✔✔

weight gain education provided based on pre-pregnant BMI.✔✔

Returning to pre-pregnant weight Manywomenareconcernedaboutweightgainedduringpregnancyandarekeentoreturntotheirpre-pregnancyweightassoonaspossibleaftertheirbabyisborn.Itisimportanttorememberthatawoman’snutritionalrequirementsremainincreasedwhilebreastfeeding.Itisessentialthatintakeisnotrestrictedtoapointwherenutritionalrequirementsarenotmet.

Womenwhogainexcessiveweightduringpregnancyareatriskofpostpartumweightretention(9).Thegreatestamountofweightlossoccursinthefirst3monthsafterbirthandthencontinuesataslowandsteadyrateuntil6monthsafterbirth(9).


Healthy eating tips for those trying to lose weightExercisingisagoodwayofstimulatingweightloss.Notonlydoesithavephysicalbenefitseg.weightlossandimprovedgeneralhealth,butalsopsychologicalbenefitsforthemother.Theexerciseneednotbevigorous.Infact,regularwalkingisaverygoodformofactivity.Encouragemotherstoexerciseregularly-atleast5timesaweekfor30minutesatatime.

Frequentbreastfeedingcanbebeneficialforweightlossandincreaseswiththelengthofthelactationcourse.

Theextraenergyrequiredtobreastfeedcanoftenbesignificant.Thesurplusfatstoreslaiddownduringpregnancy(ie.aroundhips)canbeusedtomeettheseadditionalenergyneeds.

Encouragemotherstoeatregularmeals.Skippingmealscanresultinsnackingbetweenmeals.Itcanalsoslowdownthebody’smetabolism,makingitmoredifficulttoloseweight.

Avoidchoosingfoodswithahighfatcontentiechooseleancutsofmeat,skinlesschickenandfish;choosecookingmethodsthatuseminimalfat;chooselowfatproductswherepossible;uselessmargarine,butter,oil;avoidcakes,biscuits,chocolates,lollies,cordialsandsoftdrinks.

Healthy eating tips for those trying to gain weightSomewomenalsolosealotofweightwhiletheyarebreastfeedingandfinditdifficulttomaintainanacceptableweight.ThisisNOTanindicationthatbreastfeedingshouldstop.Thefollowinglistsgivesomeideasforgainingandmaintainingweight.

Don’tskipmeals.✔■

Havethreemainmealsandthreebetweenmealsnacks.✔■

Keepeasytopreparenutritioussnacksonhandegcrackersandcheese,freshfruit,✔■

yoghurt,nuts,seeds,driedfruit,cannedbeans,flavouredmilk,fruitsmoothies,breakfastcerealsandmilk.

Prepareapackedlunchorvarietyofsnackstohaveinacontainerbesideyouwhen✔■

babyfeeds.

Prepareandfreezemealsinadvancewhenpossible(oraskyourfriends/familytohelp).✔■

Checkif client is experiencing problems returning to healthy weight range ✔✔recommend consultation with a dietitian/ nutritionist.


2.5 Groups requiring special attention during pregnancy

Vegetarian and vegansVegetarianismmeansdifferentthingstodifferentpeople.Table9outlinesthevariouseatingpracticesofdifferentgroupsofvegetariansandtheirmajorfoodsources(refertosamplevegetarianmealplanbelow).Itispossibletomeetnutrientrequirementswhilefollowingavegetarianmealplan.However,timemustbespentensuringthenutritionaladequacyofthediet,particularlywiththeincreasedrequirementsofpregnancyandlactation.Thefollowingnutrientsrequireparticularattentionwhenplanningabalancedvegetarianmealplan.

Table 9 Typesofvegetariansandmajorfoodsources

Foods eaten No red meat Lacto-ovo vegetarian

Ovo- vegetarian

Lacto vegetarian

Vegan

Plants ✔ ✔ ✔ ✔ ✔

Animalmeats (Chickenandfish)

Eggs ✔ ✔ ✔

Milkandmilkproducts

✔ ✔ ✔

Energy

Becausevegetariandietstendtobehighinfibretheyincreasesatietyandcausepeopleto‘fillup’quicker.Itis,therefore,importanttoensureadequatefoodisprovidedandweightgainisappropriate.Highenergyvegetarianfoodsincludenuts,nutorotherseedpasteseg.tahini,peanutbutteranddriedfruits.

Protein

Essentialor‘indispensable’aminoacidsmustbeobtainedfromthedietasthebodyisunabletomakethem.Animalfoodsincluding;milk,milkproducts,fishandmeatarecompleteproteinsastheycontainalltheessentialaminoacidsintheproportionsrequired.Incontrast,plantfoodsareincompleteproteinsourcesastheydonotcontainthecorrectbalanceoftheessentialaminoacids.Itis,therefore,importantthatvegetarianswhoareavoidinganimalproducts,consumeavarietyofplantfoodstoensurealltheessentialaminoacidsareobtained.Iron,zinc,calciumandvitaminB12arenutrientsthatmaybelacking.

Zinc (2)

Zincisacomponentofvariousenzymesthathelpmaintainstructuralintegrityofproteinsandhelpregulategeneexpression:Therefore,gettingenoughisparticularlyimportantfortherapidcellgrowththatoccursduringpregnancy.TheRDIforzincduringpregnancyis11mg/day.Zinccanbefoundinleanmeat,wholegraincereals,milk,seafood,legumesandnuts.

Vitamin B12

SignificantamountsofB12areusuallyfoundinanimalproducts,sointakecouldbelimited.AgoodamountcanbeconsumedbyhavingatleasttwoservesofsoymilkfortifiedwithB12daily.Foodfermentedbymicro-organisms(soysauce,miso,tempeh),manure-grownmushrooms,spirulinaandyeastmaycontainsmallamountsofvitaminB12,butthisisnotsufficienttomeetrequirementsforvitaminB12.


A sample vegetarian meal plan:

Breakfast

½cupmueslior2wheatbiscuits

Milk

1slicewholemealtoastwithpeanutbutter

1orange

Morning tea

2wholemealcrackerswithtomatoandcheese

Freshfruit

Lunch

Wholemealroll,1-2cupsofsaladwithanavocado

Milkand2tspMilo

Afternoon tea

½cupalmondsand4Tbspraisins

Dinner

1cupkidneybeans

2-3cupsservesvegetablesincludingbroccoli

Fruityoghurt

Supper

2slicesofraisintoastwithmargarine

Soybeverage,fortifiedwithcalciumandvitaminB12couldreplacemilkinveganmealplans

Check

foods from the meat, fish, poultry, eggs, nuts, legumes groups and iron ✔✔fortified cereals should be consumed each day for adequate iron and zinc intake. Soy beverages should be fortified with calcium (containing at least 115mg per 100mL) and B12

ensure sufficient energy is consumed and appropriate weight gained ✔✔

consider supplementation with a multivitamin (which includes iron, zinc, ✔✔calcium and B12) if needs are not being met

refer to dietitian for individual assessment and advice. ✔✔


TeenagersThenutrientrequirementsofpregnantteenagersareincreased.Notonlymusttheyeattoprovidethenutrientsrequiredforthepregnancy,butalsotoprovidefortheirowngrowthanddevelopmentduringpuberty.Pregnantteenagersshouldbetreatedasaseparategroup.TherearespecificRDIsforpregnantteenagersbetween14-18years.Girlswithalowgynaecologicalage(differencebetweenageofmenarcheandageatconception)requireadditionalnourishmentastheyareoftenstillgrowing.Eveniftheyhavestoppedgrowing,teenagegirlswithalowgynaecologicalagearelikelytohaveinadequatenutrientstores,becauseittakesabout2yearstobuildupstoresaftermenarch(10).

Itisimportanttoensureteenagemothershaveanappropriateweightgainduringpregnancy.Pregnantadolescentsareatriskofbothinadequateandexcessiveweightgain(11).Theyareatriskforadverseoutcomesincludinglowbirthweight,pretermdelivery,anaemia,andexcessivepostpartumweightretentionduetoacombinationofphysiological,socioeconomic,andbehaviouralfactors(11).Itisworthbearinginmindthatatthistimeinateenager’slife,thereareanumberofotherfactorswhichimpactontheireatingpatterns,forexample:peerpressure,socialsupports,lackofshoppingandcookingskillsandafearofgainingweightandbecoming“fat”.

Aboriginal and Torres Strait Islander womenSeeAboriginalandTorresStraitIslandersection

Obese pregnant womenMaternaloverweightandobesityisnowanimportantissueinaboutonethirdofallpregnanciesintheAustraliancontext(13).Increasedmaternalbodymassindex(BMI)atconceptionisassociatedwitharangeofadversematernal,obstetricandneonataloutcomes.Hypertensivedisordersofpregnancy,impairedglucosemetabolism,gestationaldiabetes,hyperlipidemia,caesareansectiondelivery,prolongedmaternalhospitalization,foetalandneonataldeath,birthdefectsandneonatalintensivecareadmissionareallconsequencesofmaternalobesity(13,14,15).

Overweightandobesityhasbeenassociatedwithreducedinitiationanddurationofbreastfeeding(16,17).Thecausesforthismaybemultifactorial.Factorstoconsiderinpoorlactationperformanceinclude:

Socio-culturalfactors,suchasconcernaboutbodyshape,lowselfesteemandpoor✔■

mentalhealth(16)

Physicalfactorsforexample,womenwithlargebreastsmayhavemechanicaldifficulties✔■

withbreastfeeding(16)

Physiologicalfactorssuchasreducedprolactinresponsetosuckling(18)✔■

Check

overweight and obese women identified as high risk during pregnancy✔✔

advice about appropriate weight gain✔✔

oral glucose tolerance test (OGTT) taken 24 – 28 weeks gestation✔✔

targeted for post partum lactation consultant assistance with ✔✔breastfeeding.


Women with diabetes in pregnancy

Pre-existing Type 1 and Type 2 diabetesWomenwithpreexistingdiabetescanhaveahealthyandsuccessfulpregnancy.Howevertheyneedclosemonitoringbyateamincludinganobstetrician,endocrinologist(orphysicianexperiencedindiabetescareduringpregnancy),diabeteseducatoranddietitiantoensurethediabetesiswellmanagedduringthepregnancy.

Womenwithpre-existingdiabeteshaveahigherriskofinfants:

havingabirthdefect;✔■

beingbornprematurely;✔■

havingalowbirthweightorbeingmacrosomic;✔■

havingdangerouslylowbloodsugarlevelsafterbirth.✔■

Itisimportantthatwomencontroltheirbloodsugarlevelsbeforebecomingpregnantandthroughoutthepregnancytominimisetheserisks.

Gestational diabetesInsomewomenduringpregnancytheirabilitytoutiliseglucosebecomesimpaired.Thehormonesproducedbytheplacentacauseinsulinresistance.Ifthebodyisunabletomeettheincreasedneedforinsulingestationaldiabetesdevelopusuallyaroundthe24th–28thweekofgestation.

Gestational diabetes is more likely to occur in (19):

Women over 30 years of age✔■

Women with a family history of Type 2 diabetes✔■

Women who are overweight✔■

Aboriginal and Torres Strait Islander women✔■

Certain ethnic groups are also at increased risk: Indian, Chinese, Polynesian/Melanesian, ✔■

Vietnamese, Middle Eastern

Women who have had gestational diabetes during previous pregnancies✔■

Women who have had difficulty carrying a pregnancy to term.✔■

GestationaldiabetesisdiagnosedafteraGlucoseChallengeTest(GCT)whichisascreeningtest.IfthisisabnormalanOralGlucoseToleranceTest(OGTT)isnecessary.

Ifgestationaldiabetesisuntreatedthereisincreasedriskofalargeforgestationalagebaby,deliverycomplicationsandlowbloodsugarlevelsofthebabyatbirth.

There are four basic components to treatment of gestational diabetes: dietary modifications, physical activity, medications and monitoring blood glucose levels.

These women should be referred to a dietitian for individualised nutritional advice. The most important points are for regular carbohydrate distribution and low glycemic index (GI) diet.

After the birth of the baby, the mother’s blood sugar levels should return to normal and an OGTT at around 6 weeks post partum should be done to confirm this.

Women who develop gestational diabetes are at increased risk of developing Type 2 diabetes later in life with a 30% – 50% chance of developing it within 15 years after pregnancy (19).


2.6 Exercise during pregnancy (20,21,22)Regularexerciseduringpregnancyisinmostcases,safeforbothmotherandbaby.Womenshouldbeencouragedtoinitiateorcontinueexerciseduringthistimetoobtainthehealthbenefitsassociatedwithsuchactivities.

Adoctor,physiotherapistorexercisephysiologistcanprovideindividualadviceforwomenaboutexerciseduringpregnancy.

Benefits of exercising regularly throughout pregnancy include:

resistancetofatigue✔■

reducedbackpain,constipation,bloatingandswelling✔■

improvedposture✔■

improvedweightcontrol✔■

stressrelief✔■

improvedsleep✔■

preparationforphysicaldemandsoflabour✔■

fasterrecuperationafterlabour✔■

fasterreturntopre-pregnancyfitnessandhealthyweight.✔■

Body changes during pregnancy

Hormonesproducedduringpregnancy,suchasrelaxin,softentheligamentsthatsupportjoints,resultinginjointsbeingmoremobileandincreasingtheriskofjointinjury.

Extraabdominalweightshiftsthebody’scentreofgravity,placingstressonthepelvisandlowerbackjoints,andcanaffectbalance.

Pregnancyincreasesrestingheartrate.

General exercise suggestions

Aimfor4to5exercisesessionsperweek.✔■

Don’ttrytoexercisetoofarbeyondcurrentfitnesslevel.✔■

Warmupandcooldownforaround10minutes.✔■

Trytoexerciseonsoftsurfaces,suchasgrassorcarpet.✔■

Avoidexercisinginthemiddleofthedayorhothumidconditions—takecarenotto✔■

overheat.

Maintainamoderateintensity—keepheartratebelow140beatsperminute.✔■

Restfrequently,particularlyiffeelingbreathless.✔■

Wearasupportivebraandfootwear.✔■

Wherecool,loosefittingclothing.✔■

Changepositionsslowlyandgradually.✔■


Suggested activitiesWater activities✔■

Walking ✔■

Swimming✔■

Yoga✔■

Dancing✔■

Pilates✔■

Pregnancy exercise classes✔■

Cycling on a stationary bike✔■

Exercises to avoidContactsportsorthoseactivitieswherethereispotentialforlossofbalancethatcould✔■

resultintraumatobaby.

Exercisinginwaterwherethetemperatureisgreaterthan32ºC.✔■

Activitiesthatinvolvejolting,jarringorrapidchangesofdirection,particularlyinthelatter✔■

stagesofpregnancy.

After16weeksavoidactivitiesinvolvinglyingflatonback—theweightoftheuterusand✔■

babycompressthemainarterybacktotheheart.Thiscanlowerbloodpressureandresultinfeelingsofdizzinessandlightheadedness.

Scubadiving-babiesarenotprotectedfromdecompressionsickness.✔■

Don’texercisewhenill.✔■

Conditions requiring medical supervision while exercising in pregnancy

Cardiacdisease✔■

Restrictivelungdisease✔■

Persistentbleedinginthesecondandthirdtrimesters✔■

Pre-eclampsiaorpregnancy-inducedhypertension✔■

Pretermlabour(previous/present)✔■

Intrauterinegrowthrestriction✔■

Cervicalweakness/cerclage✔■

Placentapraeviaafter26weeks✔■

Pretermprelabourruptureofmembranes✔■

Heavysmoker(morethan20cigarettesaday)✔■

Orthopaediclimitations✔■

Poorlycontrolledhypertension✔■

Extremelysedentarylifestyle✔■

Unevaluatedmaternalcardiacarrhythmia✔■

Chronicbronchitis✔■

Multiplegestation(individualisedandmedicallysupervised)✔■

Poorlycontrolledthyroiddisease✔■

Malnutritionoreatingdisorder✔■

Poorlycontrolleddiabetesmellitus✔■

Poorlycontrolledseizures✔■

Anaemia.✔■


Warning signs to cease exercise

Excessiveshortnessofbreath✔■

Chestpainorpalpitations✔■

Pre-syncopeordizziness✔■

Painfuluterinecontractionsorpretermlabour✔■

Leakageofamnioticfluid✔■

Vaginalbleeding✔■

Excessivefatigue✔■

Abdominalpain,particularlyinbackorpubicarea✔■

Pelvicgirdlepain✔■

Reducedfetalmovement✔■

Dyspnoeabeforeexertion✔■

Headache✔■

Muscleweakness✔■

Calfpainorswelling✔■

Medicaladviceshouldbesoughtifanyoftheabovesymptomsoccur.

Pelvicfloorexerciseshouldbedonebefore,duringandafterpregnancy.

Careshouldbetakenwithbacksupport.

Wheneverchangingposition,bendingandlifting:

tightenabdominalmuscles-particularlythetransverseabdominalmusclewhichformsa✔■

naturalcorsetinthelowerpartoftheabdomen

tightenpelvicfloormuscles✔■

uselegmuscles.✔■

Informationsheetcanbefoundat:

www.betterhealth.vic.gov.au

Check

women have no contraindications to exercise✔✔

advise of benefits of exercising in pregnancy✔✔

inform of criteria to cease exercise.✔✔


2.7 Antenatal breastfeeding education Healthprofessionalsoftenleavediscussionofbreastfeedinguntillaterinthepregnancy.Researchdemonstratesthattheearlierinthepregnancyadecisiontobreastfeedismadethemorelikelythebreastfeedingwillbesuccessful(23).Thedecisionisusuallymadebeforepregnancyandisbasedonlifeexperiences,beliefsandattitudesoffamilyandotherstobreastfeeding(24).

Antenatal education should include:

importance of exclusive breastfeeding for the first 6 months ✔■

(including the nutritional and protective benefits)

basic breastfeeding management✔■

coping with minor problems (23). ✔■

Mothersshouldbeencouragedtobecomefamiliarandcomfortablewithhandlingtheirbreasts(23).

Virtuallyeverymothercanbreastfeed,butforsomeitisnotsoeasyandlearningandpatiencearenecessary(23).

Benefits of breastfeeding for mother

Helpsuterusreturntopre-pregnantstatefaster✔■

Canhelpwithweightlossafterbaby✔■

Reduceslikelihoodofovarianandpremenopausalbreastcancer✔■

LessenslikelihoodofmotherswithgestationaldiabetesdevelopingType2diabetes(24).✔■

Formula feeding increases the risk of baby developing:

Infectionsanddiseasessuchasurinarytractinfections,gastrointestinalinfections(eg.✔■

diarrhoea)andrespiratoryillnesses(eg.asthma)andsomechildhoodcancers

Allergiesandfoodintolerancessuchascoeliacdisease✔■

Obesity,diabetesandheartdiseaselaterinlife.✔■

Benefits of breastfeeding to the community

Reducedhealthcarecostsfromillnessandchronicdiseaseprevention✔■

Reducedecologicaldamagefromproduction,packaging,anddisposalofbreastmilk✔■

substitutesandcontainers.Italsosavesfoodresources,fuelandenergy.


Guide to educationEarly pregnancy

Ask questions ‘how do you plan to feed your baby?’•✔

Importance of decision about feeding choice•✔

Assess knowledge and perceptions regarding breastfeeding•✔

Reasons mothers choose•✔

Explore and identify concerns and feelings •✔

Acknowledge and validate feelings•✔

Educate using targeted messages to address individual concerns•✔

Benefits of breastfeeding (infant, mother, community)•✔

Risks of formula-feeding•✔

Ease of breastfeeding, difficulties that may be encountered•✔

Breastfeeding with modesty•✔

Family involvement•✔

Lack of dietary restrictions and lifestyle changes•✔

Feasibility with employment•✔

Availability of people to assist•✔

Identify breastfeeding resource network (family and friends, health care providers and •✔

mother-to-mother support groups).

Later in pregnancy

Practical skills on how to breastfeed•✔

Possible difficulties and how to overcome these•✔

Importance of skin-to-skin contact and rooming in•✔

More information can be found on the following sites

HowdoIstartbreastfeeding?www.health.qld.gov.au/phs/documents/cyhu/28099.pdf

BreastfeedingGettingStartedwww.health.qld.gov.au/phs/documents/cyhu/28098.pdf

Antenatal checklist

education on healthy eating and special considerations in pregnancy ✔✔provided

calculate pre-pregnant BMI - provide education on appropriate ✔✔weight gain

breastfeeding education provided✔✔

glucose screen for gestational diabetes at 24-28 weeks gestation.✔✔


ReferencesWHO.1. Global strategy for infant and young child feeding.Geneva:WorldHealthOrganisation;2003.

AustralianGovernmentDepartmentofHealthandAgeing.(2006).Healthyeatingat2.variouslifestages:pregnantwomen.[Accessed2007May8].www.healthyactive.gov.au/internet/healthyactive/publishing.nsf/Content/pregnant-women.

WHO.3. Healthy eating during pregnancy and breastfeeding.Geneva:WorldHealthOrganisation;2001.

FSANZ.(2005).Folicacidandpregnancyadviceforwomen.[Accessed2007May4.8].www.foodstandards.gov.au/_srcfiles/FSANZ%20Folic%20Acid.pdfhttp://www.foodstandards.gov.au/_srcfiles/FSANZ%20Folic%20Acid.pdf

NationalHealthandMedicalResearchCouncil.5. Nutrient reference values for Australia and New Zealand:CommonwealthofAustralia;2006.

AndersonJ.,6. IodineEssencearticleVol43,No2March2007

FoodStandardsAustralia&NewZealand,2005FoodandPregnancy.[online]7. www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfmMarch2007.

InstituteofMedicine.(1990)8. Nutrition during pregnancy, weight gain and nutritional supplements. Report of the Subcommittee on Nutritional Status and Weight Gain during Pregnancy, Subcommittee on Dietary intake and Nutrient Supplements during Pregnancy and Lactation, Food and Nutrition Board.Washington,DC:NationalAcademyPress:1-233.

CrowellDT.(1995)Weightchangeinthepostpartumperiod:areviewoftheliterature.9.JournalofNurseMidwifery;40:418-23.

JobJ,CapraS,AshS.(1995)Nutritionalassessmentofpregnantteenagersattendinga10.metropolitanpublicmaternityhospitalinBrisbane.1.NutritionalIntakes.AustralianJournalofNutritionandDietetics,Vol52,No.2:76-82.

NeilsenJ,GittelsohnJ,AnlikerJ,O’BrienK.(2006)InterventionstoImproveDietand11.WeightGainamongPregnantAdolescentsandRecommendationsforFutureResearch.JournaloftheAmericanDieteticAssociation;106:1825-1840.

SIGNAL:12. National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000 – 2010.NationalAboriginalandTorresStraitIslanderNutritionWorkingParty

CallawayLK,P.J.,ChangAM,McIntyreHD,13. The impact and prevalence of overweight and obesity in an Australian obstetric population.MedJAust,2005.


Cnattingius,S.,etal.,14. Prepregnancy weight and the risk of adverse pregnancy outcomes.NEnglJMed,1998.338(3):p.147-52.

KingJ.(2006)MaternalObesity,metabolism,andPregnancyOutcomes15.

DonathSM,AmirLH.(2000)Doesmaternalobesityadverselyaffectbreastfeeding16.initiationandduration?BreastfeedingReview;8(3):29-33

LoveladyCA.(2005)Ismaternalobesityacauseofpoorlactationperformance?Nutrition17.Reviews;63,10:352-355.

RasmussenKM,KjolhedeCL.(2004)Prepregnantoverweightandobesitydiminishthe18.prolactinresponsestosucklinginthefirstweekpostpartum.Pediatrics;113:1388-9

DiabetesAustralia.(2004)GestationalDiabetes.DiabetesAustralia.19.

RoyalCollegeofObstetriciansandGynaecologists.(2006)ExerciseinPregnancy20.(StatementNo.4).

BetterHealthChannel2006.PregnancyandExerciseFactsheet.[online]21.www.betterhealth.vic.gov.au.March2007.

AmericanCollegeofObstetriciansandGynaecologists.(2003)ExerciseDuringPregnancy22.PatientEducation.[online]www.acog/publications/patient_education/bp119.cfm?printerFriendly=yes.March2007.

NationalHealthandMedicalResearchCouncil.(2003)23. Food for Health. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant Feeding Guidelines for Health Workers.CommonwealthofAustralia,Canberra.

BrodribbW.(2004)BreastfeedingManagement.Thirdedition.AustralianBreastfeeding24.Association.

QueenslandHealth(2005)ChildandYouthHealthFactsheetsBreastfeeding:25.bestforbaby,bestforyou.[online]www.health.qld.gov.au/child&youth/factsheets

RiordanJ.(2005)26. Breastfeeding and Human Lactation.Thirdedition.JonesandBartlettPublishersInc.

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