eNutrition
a LaFrance Consulting Services™ e-Course
Nutrition for Nursing Students, independent study

In the best of all possible worlds, you as a OB/GYN nurse will encounter the patient long before she intends to become pregnant, because you would like to provide guidance on advance preparation prior to pregnancy in addition to on-going counseling during the pregnancy [it would be helpful if you could also counsel the intended father but don't count on ever getting the opportunity]. In the real world, you will probably encounter the patient first when she thinks she might be pregnant. But in the worst of all possible worlds, she [a young teen] will present in the ER with a severe upset stomach and on examination will be dilated already; later after the birth of her child, she will assure you that she has never done anything that could cause pregnancy [in spite of convincing evidence to the contrary].

pregnancy

Especially for the younger first-time mother-to-be, you may need to provide considerable patient education in order to increase the chances of a successful pregnancy. A successful pregnancy occurs when the child is born with a reasonable chance of survival and a reasonable expectation for a quality life, and the mother can be expected to be returned to her pre-pregnant state of health [or better] in a reasonable amount of time. When the patient has had previous successful pregnancy (or pregnancies), the amount of education needed should be less. I would suggest that you do not need to wait for the patient to disclose how many previous pregnencies she has had; a quick glance at her fully clothed abdomen may provide an initial assessment of the probable number of previous pregnancies [as for any initial Nursing assessment, it is mandatory that you remain prepared to revise the assessment as you obtain more information]. If the patient's abdomen is flat there is a good chance that she has never been pregnant [although a former A & P student of mine took great offense (reporting sexual harrassment to the Dean, in spite of my not having pointed her out as an example of a flat abdomen) to this statement, because she had three children apparently by natural child birth and a flat abdomen; I apologized to the entire class, noting that I was unaware that I could not discuss human anatomy in an A & P class for Nursing students; the Dean agreed with me that it was reasonable for me to discuss anatomy in A & P class]. A gently rounded abdomen suggests either one previous pregnancy or a long term lack of exercise (and chronic poor posture). Any rounding beyond a gentle curve suggests either multiple pregnancies or recent and dramatic weight loss (either of which could account for loose abdomenal skin and even stretched underlying muscles). As you are thinking about how many pamphlets to offer her, you might consider the follow up question, “So, how many previous pregnancies have you had?” I would expect her to have some vague idea as to the correct answer.

    Assume your patient is thinking about becoming pregnant for the first time, and is not yet pregnant; and remember this is a Nutrition for Nursing students class. It would be a good idea to assess her nutritional status, particularly for weight [remember dress size is more important than weight before the pregnancy begins; but weight increase measured by a bathroom scale is important during the pregnancy], calorie intake to maintain healthy weight, folate, vitamin A, Calcium, vitamin D, Iron, Iodine, and the omega-3 fatty acids EPA & DHA; and no vitamin overdosing. Any problems with dietary intakes should be “fixed” during the planning to become pregnant stage, if possible. The same nutrients can be assessed if she is already pregnant before you first see her, but how you can adjust the diet will be different. In the planning stage, we want to address dietary issues by adjusting the patients dietary intakes. Folate, Calcium and vitamin D deficiencies can be adjusted by non-food supplements. Time permitting before the pregnancy begins, we would like to see weight adjusted toward “normal, healthy” for her age and height. Once the pregnancy has begun, vitamins and minerals are to be adjusted with food and non-food supplements [this is the only time that I recommend using non-food supplements]. The recommended amounts of the critical nutrients are continually being revised (which nutrients and recommended intakes; plus recommended weight gain), so if you expect to deal with this population of patients, you will need to keep up on the literature on these recommendations. Once the pregnancy begins, weight not dress size becomes important to the prospects for a successful pregnancy. You will encounter OB/GYN doctors who think “morning sickness” is strictly psychological (but that is because HE never experienced it), but it is a real condition with a real physiological cause (probably hormone production by the placenta and by the fetus entering the maternal circulation0. If your patient reports morning sickness, you need to be aware that this can compromise nutritional status and hydration, so you may have to monitor for evidence of such problems.
    A few events during fetal development have implications for nutrition, and thus are worth mentioning here:
  1. from conception to implantation (about 12 days), the developing child is technically an embryo, and derives its nutrients from the yolk of the egg. The yolk was produced before ovulation, mostly in the previous month, so the nutrient density of the yolk depends on the mother's pre-pregnant nutrient status (two to three months pre-pregnancy).
  2. from implantation to birth, the developing child is technically a fetus, and derives its nutrients from maternal circulating blood, so the available nutrient density depends on current maternal nutrient status. The text claims that the fetus can not out-compete the mother for nutrients, but at least for Calcium and Iron the data strongly suggest that the fetus can harvest these nutrients (and perhaps others) from maternal tissues if there is an inadequate supply available from maternal circulation. The mother may win out in competing for dietary nutrients, but the fetus [parasite or not] can extract [digest] nutrients from maternal tissues as needed.
  3. during the first trimester, organs are forming in the fetus, so these forming organs are sensitive to those nutrient deficiencies and toxins (such as tobacco, alcohol, and drugs) relevant to the specific organ forming (for example, alcohol in small doses may reduce IQ by 10 or more points [down to IQ = 60]).
  4. during the second trimester, the fetus primarily gains weight overall and in specific organs, so is sensitive to maternal calorie intake (and perhaps cholesterol intake).
  5. during the third trimester, the fetus is gaining weight to term-weight, and its organs are maturing, so is sensitive to specific vitamins and minerals needed for organ maturation; and can fail to gain sufficient weight if the mother smokes (or is exposed to second hand smoke); smoke probably has a similar effect during the second trimester as well.
The mother will undergo an number of changes in nutritional needs during the pregnancy. She is not literally “eating for two” because there is a substantial difference in body weight between the two (mother and fetus). That said, overall nutrient intake by the mother must increase to meet the demands of the fetus while maintaining health in the mother. A 120 lb mother carrying a 4 lb fetus will need more than 103.3% [((120 + 4)/120) = 103.3%] as much nutrients because the fetus demands more nutrients per pound than the mother does because the fetus is growing rapidly, and the mother should not be. The fetus will require more than its “share” of protein and fatty acids (including cholesterol) from red meat. Many women report cravings [to the best of my knowledge, only male stand-up comedians think pregnant women crave pickles and ice cream]. Given my hypothesis [in the first lecture under Attitudes and Behavior, week 1] that cravings result from the hypothalamus detecting a decline in some nutrient in the blood stream,signaling the brain to provide the nutrient, and the brain selecting from sub-conscious memory some food which supplied that nutrient, and labeling the food as a craving; it seems reasonable to empower women to give in to any food cravings; but not to cravings for non-food substances (such as mud or dirt).

breast-feeding

Before discussing breast-feeding, we need to cover another aspect of the psychology of pregnancy. I get the impression from a once upon a time pregnant woman (and mother of our three children) that the ninth month of pregnancy lasts at least three months, and each day from the “due date,” which seems to have been determined by throwing darts at a calendar, to the delivery takes at least a month or two. Then there is the delivery sometimes followed by post-partum blues [speculating, it could be caused by loss of the fetal and placental hormones; or perhaps by some other cause]. The biggest risk in post-partum blues [which are definitely real] is that the blues can become sub-clinical depression, which in turn can become clinical depression (and can result in “failure to thrive” or even death of the new-born). And what, you may be wondering, does this have to do with breast-feeding? If the new mother's health care providers over-emphasize the importance of breast-feeding, and for whatever reason she is unable to feed the child, this may provide her with the necessary proof of her failure as a mother to allow her to skip from post-partum blues straight to clinical depression.
    The National Dairy Council [the trade organization for the cow's milk industry] in their advertising campaign of a few years back got it only half right. Yes, “Milk is the perfect food for babies,” but Cow's milk [whether from the contented cows of Wisconsin or the happy cows of California (or the disgruntled cows of Indiana?)] is the perfect food for cow's babies; goats milk is the perfect food for goat's babies; cat's milk is the perfect food for cat's babies; rhinoceros' milk is the perfect food for rhinoceros' babies; and Human's milk is the perfect food for Human's babies. Each mammalian species (including Homo sapiens) makes milk which is nutritionally balanced for that species, and typically includes no allergens for the species. However, some unusual substances in the mother's diet can find their way into the milk; the not so contented cows of Kansas [back in the dark ages when the milkman delivered milk to your doorstep, and when I was a young child] produced garlic-flavored milk in the spring because garlic was the first plant to become green in the cow pastures of Kansas. I know from personal experience that garlic-flavored cow's milk does not improve the flavor of Kellog's™ Corn Flakes [and according to my younger brother, nothing could improve the unpleasant taste of “the Breakfast of Champions”]. The current guidelines for an appropriate diet for the breast-feeding mother are in Table 29.8, pg. 29-15 in your text; but again, if you expect to deal with this population of patients, you will need to keep current with the literature concerning recommended diets for lactating women. Alcohol is not likely ever to be added back into the recommended diet; clinical tests have confirmed that Human's milk has the same alcohol percentage as does maternal blood (at the time the milk is produced), so junior will have to give up his/her Chardonnay-flavored mother's milk [you should not add Chardonnay to cow's milk either; although for a brief time in the distant past, some pediatricians did suggest adding whiskey to cow's milk served to “colicy” [diagnosed by the mother, not the pediatrician] infants at bed time [the babies did sleep well, but their hangovers aggravated their grumpiness in morning (and reinforced the mother's diagnosis of colic)].
    So, “should your patient breastfeed?” The only correct answer, from a Nursing perspective is this is a decision which only the mother can make, but it must be an informed decision. This means you must present the pros and cons of breast feeding and the pros and cons for formula feeding. The two biggest pros of breast-feeding are (1) mother's milk is the perfect food for mother's babies, and (2) mothers who breast-feed have been shown to form a stronger bond with their babies than do mothers who bottle feed their babies [and breast-feeding is a birth control method,; breast feeding mothers may not ovulate for three or six months after giving birth, while mothers who do not breast feed will usually ovulate the second or third month postpartum. The biggest con for breast feeding is convenience; the lactating mother cannot miss a feeding (if she does not feed the kid, she will have to milk herself at about the same time as the next expected feeding time. Failure to nurse (or to milk) may lead to cessation of lactation; and failure to nurse or milk the breasts for 24 to 36 hours usually causes cessation of lactation [based on data collected by midwives from wet nurses over a century ago: wet nurses had to either get a new client immediately, or express their milk at expected feeding times; otherwise, they would have to get pregnant to resume lactating]. A second disadvantage of breast-feeding is that it gives husbands an excuse not to take the 2 am feeding shift. The two biggest pros of formula feeding are (1) convenience (and lack of embarassment associated with feeding the kid in public places), and (2) it is far easier for the spouse to participate in the feeding of the infant and the associated bonding with the child [fathers who never feed their infants have been shown to fail to bond with their children until the children learn to talk, if then]. The single biggest con of formula feeding is the risk of allergic reactions in some substances in the formula.

Infant

As of the moment that birthing has completed, the now infant must learn to function in a universe where all of the rules have 'abruptly' changed (again). For the past eight and a half months or so, the fetus has been learning how the universe works, and it was a good universe where needs were automatically met immediately. [The earlier change, at about 2 weeks, was from a yolk-dependant embryo to a fetus with placental nutrient supply. Without a brain, the embryo probably did not 'learn' the rules of this universe, so the change of rules was not important to the fetus.] Now, however, some functions must be handled by the infant. These include breathing, and numerous homeostasis functions [temperature regulation, regulation of blood sugar, ...] Not only that, needs not provided by the infant itself must be communicated, yet the newborn infant's vocabulary consists of a single 'word,' a cry. [there was a series of televised specials (in 2006-7) suggesting that there are five fundamentally different cries in the vocabulary of infants, but, in my opinion, these develop over time as the infant learns to modify the basic cry to communicate more accurately. Most first time mothers cannot distinquish among these different cries anyway, so “to communicate more accurately” usually doesn't happen.] Unfortunately for the infant, the rules of its universe will undergo a long series of major changes…
  A major difference between children and adults that seems not to be recognized by most authors discussing children is the speed at which time passes. Most mid-life and older adults have an intuitive grasp that the speed at which time passes has increased, but have no idea what that means. When I taught at a parochial college-prep high school a “few” years ago, I tried to determine why teenaged Humans continued sunbathing as if the risk of skin cancer was not a issue. I finally realized that these creatures (16 year old High School Students) often behave as if “forever– has lasted thus far only as long as they have been here to observe it. “Ah ha!”, I thought, “That's it. If forever continues into the future for as long as it lasted in the past, a 16 year old will be only 32 years old at the end of forever [and skin cancer affects very old people, like 64 years old.”. Continuing this thought as a explanation of how time works [move over Steven Hawkings, I know how time works], at the time birthing begins, the fetus believes itself to be 8 months old, because its brain has been mature enough to be capable of observing time for only about 8 months [although the fetus is one month older than that]. One hour after the start of birthing, the infant will be slightly less than one one-hundredth of a percent older. One day after birthing began, the infant will be two tenths of a percent older. To get to its “one month birthday” it must increase its age by twelve and a half percent; and its first year birthday will not happen until one and a half lifetimes (forevers) up to the start of birthing have passed. For the one year old, the second birthday will be 60% of its lifetime (thus far) into the future; one month is 5% of a lifetime; and a day is almost one tenth of a percent of its lifetime. If the one year old has a 20 year old parent, the parent's 21st birthday will occur within 5% of their lifetime so far, or about as long as a month for the one year old. The fifty year old grandfather does not even have to wait for 2% of his lifetime for his next birthday. Similarly, the five year old wants to know, “Are we there yet?” because the last hour in the car felt like 0.001% of a lifetime, but the 30 year old parents thought it took only 0.0002% of a lifetime [one fifth the time perceived by the five year old] while the 70 year old grandparent thought it was only 0.00008% of a lifetime [less than half (4/10) the time perceived by the 30 year old; less than one tenth the time percieved by the 5 year old].
    Growth works like time. The newborn will double its weight in the first four to six months, but will only have increased by 50% more in the second six months. The weight from the one year weight will not double again until the fifth year. Height increases by 50% within the first year, and thereafter as growth spurts over about 19 to 22 years. “Growing pains” probably result when long bone growth exceeds muscle growth, stretching the muscles. Overall development takes about the same 19 to 22 years, except for cognitive development which seems to continue for at least 24 years, or more likely, a lifetime or until non-alzheimers age-related demenia sets in (which ever occurs first).

Nutritional Needs

Nutritional needs for developing infants and young children do not follow the usual “dosing per unit of body weight” concept. Due to the higher surface to volume ratio than adults have, the small child loses more heat than would an adult, and therefore requires more carbohydrate and lipid calories per unit body weight than their adult care-givers. In addition, the small child ought to be growing faster (pounds per day) than their parents, which places an additional demand on carbohydrate and lipid calories. Growth and development also places rather high demands on the essential fatty acid (and cholesterol) supply for the manufacture of cell membranes [the small child adds a huge number of cells per day compared to an adult] and manufacture of steroidal hormones. The protein demands (including red meat proteins) is high due to the manufacture of large quantities of structural proteins, although the number of enzymatic proteins per unit body weight is only slightly higher in the child due to elevated BMR (basal metabolic rate). Vitamins, as co-enzymes, should be only slightly higher than for adults on a per unit body weight basis. I have been unable to find any specific comparisons between dietary mineral demands between children and adults, but there are no shortage of cautions against mineral overdosing for children. Children from birth to High School graduation have a strong need for the psychological support and learning of sociological skills provided by “quality [family] time&$8221 (or “nurturing”) surrounding feeding.

feeding skills

Remember when I warned you [too late to assist you personally] that the rules of the Known Universe are subject to frequent, and sometimes drastic, revision. This is nowhere more apparent than in the realm of “feeding skills.” During the child's first (fetal) forever, the universe is well-behaved. Most environmental factors such as temperature are reasonably constant, and nutritional (and other) needs are met via placental delivery automatically and virtually immediately. Then, in less than one one-thousandth of one percent of forever, ALL of the rules of the Universe change! Nobody warns you that you will have to breathe to obtain oxygen; regulate your own temperature and blood chemistry [and you didn't really like chemistry class]. And this new Universe has People in it, so you're no longer alone. Then, you notice a new feeling, which turns out to be hunger. None of the Human-like People around you seem to know that you are hungry, so how are you supposed to tell them about this need. Eventually one Person (we'll call her “Waa;” she seems to respond to that) sticks something, a breast or a bottle, in your mouth. Now they expect you to suckle to get food out of the structure, and you think “you mean I have to work for food?” About the time you get this suckling process to work fairly consistently, they change the rules again. Now you have to hold your own bottle, and suckle while holding it up. It takes a while, but finally you get this new way of getting nutrients working moderately well [still lose a lot of the nutrients onto your chin and front]. And you guessed it, new rules. The bottle [they called it a sippy cup] has handles, so it's easier to hold, but the nipple has taken a strange shape, and you have to slurp to get nutrients out of it [and it still spills a lot on your front]. Then for no reason, one day the nipple on the sippy cup becomes a straw. You're back to sucking but now you have to hold the cup down not up. This version of the Universe has lost its consistency - some times its the straw in the cup, other times it is the sippy cup. As the Universe continues to change, you encounter “finger food” which you are supposed to put in your mouth, but where is this mouth of which you speak? Try it… without a mirror look at your mouth. Can you see it? or are your nose and cheeks in the way? So how is eye - hand coordination expected to help you put objects (like Cheerios™) in a mouth you can't see? And they introduce Engineering designs like spoons. Again try this one at home [when no one is watching you make a fool of yourself]… grasp a spoon in your fist like a baby does; stick it into some soup and lift the spoon toward your mouth by bending your elbow and holding your wrist straight. Where did the soup go?

    Back to advising parents, first time mothers often wonder when they should introduce solid foods. Realistically (and contrary to some medical advice), the infant will signal the correct time to start. One day they will seem to still be hungry after normal feedings, yet will spit up any excess formula over the normal feeding. On that day, tomorrow is a good time to add a little rice [lowest risk of food allergies] cereal to the formula (or breast milk) to thicken it a bit. If the kid gets to be 6 months old and still is not on solid food, it is again about time to add the rice cereal to the formula.Initially, the infant should be able to suck the rice cereal - milk (formula) mixture through the bottle nipple. The amount of rice cereal can be increased and milk (or formula) decreased every few days (3 to 5). As the mixture becomes difficult to suck through the bottle nipple, you can run a sterilized pin through the opening to enlarge it. As soon as the mixture is thick enough for spoon feeding, the child should be securely strapped into a high chair and spoon fed. This must be a pleasant experience for the child, so the mother/father is not permitted to stress about the mess. The child is empowered to determine how much they want to eat, so they can learn to eat just until they are no longer hungry, and no more! [step one in “solving” the obesity problem in America]. And step one in the quest to improve the typical American's Wellness through diet (alone) is to teach the infants and toddlers to enjoy their meals. Persons who eat to enjoy the eating experience tend to healthier than persons who “live to eat,” yet eat quickly to get it over with. Once the infant/toddler learns to enjoy the eating experience, the groundwork has been established for choosing foods to eat based on flavor and on nutritional value (since nutritional value follows intuitive pleasureable flavors).
  Note to new mother's: you are not required to eat your baby's left-overs; the starving Armenians (or what ever ethnic group is the politically correct starving peoples) will starve just as fast whether you eat your baby's left overs or not. Not even home-less dumpster divers are going to eat discarded baby food on purpose. You, the new mother, however will manage to avoid losing your pregnant weight, and even gain a few extra tens of pounds besides, simply by cleaning your baby's plate by eating their left-overs. And, even worse, your baby will learn to eat whether or not they are hungry in order to model the parental behavior [step 1 in assuring that the obesity problem will become worse].
    Once you begin introducing solid foods to an infant, you should add only one food at a time, and MONITOR for food allergy! You, the health care provider will need to check current guidance for preferred order of introduction, in case this advice changes again. By nine months of age, the infant/toddler can begin eating strained vegetables, then strained fruits. Start with those fruits with relatively mild tastes, then introduce fruits with bolder tastes. Any parent who ever took a taste of baby food to “prove” that the stuff really is delicious already knows this, but strained meats are not even marginally edible. Fortunately, by one year (12 months), the child will be able to switch to adult foods; sooner if they have enough teeth to chew food.

nutrition problems



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revised: 05 Jun 2009