Nutrition Management During Pregnancy and Lactation
Manual of Clinical Nutrition Management A- 16 Copyright © 2013 Compass Group, Inc.
mg of ferrous gluconate, or 100 mg of ferrous fumarate can fulfill this additional need. Iron deficiency anemia
is the most common anemia during pregnancy. If the maternal iron stores are low, 60 to 120 mg of iron may
be recommended (4), in addition to a multivitamin supplement containing 15 mg of zinc and 2 mg of copper,
since iron may interfere with the absorption of zinc and copper (3). If the laboratory values indicate
macrocytic anemia, vitamin B 12 and folate levels should be assessed.
Zinc and copper: Iron can interfere with the absorption of other minerals. Therefore, women who take daily
supplements with more than 30 mg of iron should add 15 mg of zinc and 2 mg of copper (3). These amounts of
zinc and copper are routinely found in prenatal vitamins.
Folate: The DRI for folate for women 19 to 50 years of age is 600 g/day (7,8). This level of folate should be
consumed through synthetic folic acid from fortified foods or supplements or both, in addition to the intake of
folate from a varied diet (3,6). Compared to naturally occurring folate found in foods, the folic acid contained
in fortified foods and supplements is almost twice as well absorbed, so that 1 g from these sources is
equivalent to 1.7 g of dietary folate (3). Women who take folic acid at the time of conception are less likely to
give birth to a child with neural tube defects (9-12). To ensure that blood vitamin levels are adequate at the
time of neural tube closure, supplementation should begin at least 1 month before conception (3). Women
who take multivitamins containing folic acid 1 to 2 months before conception have a reduced risk of having a
child with orofacial clefts (13). Research also indicates that abnormal folate metabolism may play a role in
Down syndrome and other birth defects (3). Women who have delivered an infant with neural tube defects
may need to consume more than the recommended amount of dietary folate equivalents (3). Until more
evidence is available, it is recommended that women older than 19 years of age not exceed the tolerable
upper limit of 1,000 g/day of folate from foods, fortified foods, and supplements (3). Although extensive
public education about the importance of folic acid has occurred in the past decade, the percentage of women
who take folic acid remains low at approximately 33% (3). Dietitians should provide nutrition education and
counseling as to the importance of folic acid consumption, especially for women who are nonwhite, Hispanic,
low-income, or young or who lack a high school education (3).
Calcium: Due to the increased efficiency of calcium absorption during pregnancy, calcium requirements for
pregnant women are similar to the requirements for women who are not pregnant. A daily intake of 1, 000
mg is recommended for pregnant and lactating women (13) older than 19 years (<19 years old, 1,300 mg/day)
(13). Women who avoid dairy products and rely on calcium-fortified orange juice or other fortified foods may
have lower intakes of vitamin D and magnesium than milk consumers, therefore their diets should be
evaluated for the adequacy of these nutrients (3).
Sodium: Sodium is required during pregnancy for the expanding maternal tissue and fluid compartments and
to provide fetal needs. Routine sodium restriction is not recommended (6).
Vitamin A: High doses of vitamin A during pregnancy have caused birth defects of the head, heart, brain, and
spinal cord. The Food and Drug Administration (FDA) and the Institute of Medicine recommend that vitamin
A intake be limited to the DRI of 5,000 IU during pregnancy (14, 15 ). In addition, pregnant women should limit
their intake of liver and fortified cereals. The FDA recommends that women of childbearing age choose
fortified foods that contain vitamin A in the form of beta carotene rather than preformed vitamin A. A high
intake of fruits and vegetables rich in beta carotene and other carotenoids is not a concern (15).
Fluids: Adequate fluid intake is extremely important. The recommended daily fluid intake for pregnant
women is 8 to 10 cups or 35 to 40 mL/kg of pregravid weight (3).
Fiber: Ingestion of fiber is important to speed digestion and prevent constipation and hemorrhoids. The
20 02 DRI for adequate intake of total fiber is 28 g/day for all age groups during pregnancy (3, 6 ).
Other Substances
Alcohol: The consumption of alcohol during pregnancy may result in fetal alcohol syndrome. Even light to
moderate drinking may cause neurologic abnormalities not detectable at birth. Since a safe level of alcohol
consumption has not been determined, pregnant women should abstain from alcohol (3).
Caffeine: Caffeine is rapidly absorbed and crosses the placenta freely. After ingestion of 200 of mg caffeine,
intervillous blood flow in the placenta is reduced by 25% (16). High levels of caffeine intake are associated
with delayed conception, spontaneous miscarriage, and low birth weight, but not with birth defects (3,16). The
position of the Academy of Nutrition and Dietetics is that pregnant women should avoid caffeine intakes
greater than 300 mg/day (3). Some studies have found no adverse effects as a result of moderate caffeine