Nutrition in Pregnancy

CLINICAL PRACTICE GUIDELINE
NUTRITION FOR PREGNANCY
Nutrition for Pregnancy
Institute of Obstetricians and Gynaecologists,

Royal College of Physicians of Ireland
and
Directorate of Clinical Strategy and Programmes,
Health Service Executive
Version 1.1
Date of publication: August 2013
Guideline No.27
Revision date: August 2016

1
Table of Contents
Key Recommendations ............................................................................... 4
1.
Purpose and Scope ......................................................................... 5
2.
Background and Introduction ........................................................... 5
3.
Methodology .................................................................................. 6
4.
Clinical Guidelines .......................................................................... 8
4.1
Weight Gain ................................................................................... 8
4.2
Nutrient Overview ......................................................................... 10
4.3
Macronutrients ............................................................................. 13
4.3.1
Energy ........................................................................................ 13
4.3.2
Protein ........................................................................................ 13
4.3.3
Fats ............................................................................................ 14
4.4
Micronutrients .............................................................................. 15
4.4.1
Folate/ Folic acid ........................................................................... 15
4.4.2
Iron ............................................................................................ 16
4.4.3
Calcium ....................................................................................... 17
4.4.4
Vitamin D .................................................................................... 17
4.4.5
Iodine ......................................................................................... 18
4.4.6
Supplementation .......................................................................... 18
4.5
Foods to Avoid ............................................................................. 19
4.5.1
Toxicological substances ................................................................. 19
4.5.2
Food borne infections ..................................................................... 20
5.
Specific diets................................................................................. 20
5.2
Allergies ....................................................................................... 20
6.
Hospital Equipment and Facilities..................................................... 20
7.
Provision of information on best practice for infant feeding ................. 21
8.
References ................................................................................... 22
9.
Implementation Strategy ................................................................ 29
10.
Key Performance Indicators ............................................................ 30
11.
Qualifying Statement ..................................................................... 30
Appendix 1 - Useful websites ..................................................................... 31

Appendix 2 Chapter 1: FSAI Best Practice for infant feeding in Ireland .... 32
Key Recommendations
All women planning a pregnancy, or likely to become pregnant should be
advised to:
1. Take a daily supplement of 400 micrograms (400g/0.4mg) folic acid;
higher does are required for those with a history of neural tube defects or
pre-existing diabetes mellitus.
2. Pregnant women and women planning pregnancy should be encouraged to
eat a healthy, balanced diet incorporating foods based on the Health
Service Executive (HSE) national Food Pyramid Iron, calcium, vitamin D
and long chain omega-3 polyunsaturated fatty acids are particularly
important.
3. Avoid foods or food supplements which may be teratogenic or harmful to
their baby.
4. All women booking for antenatal care should have their Body Mass Index
calculated accurately.
5. Ideally women who are underweight, overweight or obese should be seen
for pre-pregnancy dietary counseling in the community to optimise weight
prior to conception and therefore reduce associated risks during
pregnancy.
1. Purpose and Scope

The purpose of this guideline is to improve the management of nutrition during
pregnancy while demonstrating a link between good nutrition during pregnancy
and a favorable pregnancy outcome.
These guidelines are intended for healthcare professionals, particularly those in
training, who are working in HSE-funded obstetric and gynaecological services.
They are designed to guide clinical judgment but not to replace it. In individual
cases a healthcare professional may, after careful consideration, decide not to
follow a guideline if it is deemed to be in the best interest of the woman.
Separate guidelines are available for the management of obesity (HSE 2011
Obesity and Pregnancy Clinical Practice Guideline) and diabetes during
pregnancy (HSE 2010 Guidelines for the Management of Pre-Gestational
Diabetes Mellitus from Pre-Conception to the Postnatal Period).
2. Background and Introduction

Maternal nutrition at conception and during pregnancy influences the growth and
potential development of the fetus and contributes to the maturity of a healthy
baby.
It was commonly accepted that the fetus was nourished adequately at the
expense of maternal stores and needs, however, it is becoming clear that this
may not always be the case, and that fetal development can be less than
optimal if certain nutrients are not available during particular sensitive windows
of development (Zeisel, 2009). Nutrition during pregnancy effects not only fetal
development, but also the risk of chronic diseases for that infant in adulthood
(Koletzko, 2012, Silveira et al, 2007). The Barker Hypothesis first described
the link between fetal development and later development of chronic diseases
over 20 years ago (Barker, 1993; Barker et al, 1995). The critical window of
opportunity seems to occur from conception until 24 months of age and is now
commonly referred to as the first 1000 days. Health professionals working with
mothers and babies during this key time have a unique opportunity to influence
lifelong health of mother, infant and the family unit, by encouraging an
appropriate diet.
Poor in utero nutrition can increase adult risk of cardiovascular disease (Kajantie
et al, 2005), high blood pressure (Huxley et al, 2000), obesity (Tounian, 2011;
Boney, 2005) and metabolic syndrome (Barker et al, 2005). Even babies with
seemingly normal birth weight have increased risk of cardiac death in later life if
malnourished in utero (Barker et al, 2012). Obese women are more than twice
as likely to give birth to a large for gestational age baby compared to a normal
weight women (Sebire et al, 2001), which significantly increases the risk of
complications associated with delivery (Boulet, 2003). Maternal diet can
influence the type of fetal adipose tissue, which may explain the babys risk of
developing insulin resistance and subsequent diabetes in later life (Symonds et
al, 2012). The fuel-mediated in utero hypothesis suggests that increased
glucose and lipid intake during pregnancy results in obesity in later life for the
baby (Koletzko et al, 2012). Improved diet and lifestyle regimens potentially
5
reduce this risk (Nelson et al, 2010; Moses et al, 2005). For example,
replacement of high glycaemic index foods with low glycaemic index foods has
been shown to significantly reduce gestational weight gain in obese women
(Walsh et al, 2012).
Obese women are at an increased risk of developing gestational diabetes
mellitus (GDM) which further increases complications in pregnancy (Dennedy
and Dunne, 2010). These risks include birth weight above 90th centile for
gestational age, increased need for caesarean delivery, clinical neonatal
hypoglycaemia, cord blood serum c-peptide level above 90th centile, premature
delivery, shoulder dystocia, hyperbilirubinemia and pre-eclampsia. GDM patients
who are overweight or obese, have higher risks of complications (Owens et al,
2010). Pre-pregnancy weight loss is recommended for all obese women and is
particularly beneficial in nulliparous women considering their first pregnancy
(Dennedy and Dunne, 2010). GDM recurs in second and subsequent pregnancies
(Kim, 2007), where patients will require more intensive monitoring and
management with dietary intervention indicated from the outset.
The national food pyramid provides a basis on which to plan a pregnant womans
diet however, she will require increased levels of certain nutrients including folic
acid, iron and long chain omega-3 polyunsaturated fatty acids (LCPUFA).
Sufficient dietary intake of calcium and vitamin D is also important throughout
pregnancy. All pregnant women should receive up-to-date, evidence-based
nutrition and lifestyle information during pregnancy. Groups identified as being
at particular risk of nutritional deficiency, or who would benefit from nutritional
intervention include adolescents, women living on low-incomes, women
observed to have a low or high body mass index at the beginning of pregnancy
and women at high risk of pre-eclampsia or diabetes. It is essential that support
structures are put in place to assist these women. Women with underlying
disease states, including type 1 and 2 diabetes, Phenylketonuria and coeliac
disease, which warrant specific dietary advice should be seen by the dietitian.
Pregnancy is a time which provides a unique opportunity to influence the long
term health of the infant and mother. Many women are self-motivated to make
positive changes to diet and lifestyle while pregnant. Just as targeting pregnant
women and their partners for smoking cessation interventions during the
antenatal period has been shown to be particularly effective (National Service
Framework, 2000), diet and lifestyle change should be promoted at this
opportunity to improve long term health outcomes.
3. Methodology
Medline, EMBASE and Cochrane Database of Systematic Reviews were

searched using terms relating to nutrition in pregnancy, Fetal
programming and nutrition, First 1000 days, diet and pregnancy.
Searches were limited to humans and restricted to the titles of English
language articles published between 1990 -2012
Relevant
meta-analyses,
systematic
reviews,
intervention
and
observational studies were reviewed.
Guidelines reviewed included:
FSAI 2011 Scientific Recommendations for a National Infant Feeding Policy,

2nd Edition.
FSAI 2012 Best Practice for Infant Feeding in Ireland: From pre-conception
through the first year of infants life.
HSE 2011. Obesity And Pregnancy Clinical Practice Guideline. Institute of
Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and
Clinical Strategy and Programmes Directorate, Health Service Executive. April
2011.
FSAI 2011. Healthy Eating and Active Living for Adults, Teenagers and
Children Over 5 Years A Food Guide for Health Professional and Catering
Services.
HSE 2010 Guidelines for the management of pre-gestational diabetes Mellitus
from preconception to the postnatal period. July 2010 available at
www.hse.ie.
DoH/HSE 2012 The National Healthy Eating Guidelines - Your Guide to
Healthy Eating using the Food Pyramid.
NICE 2008 Improving the nutrition of pregnant and breastfeeding mothers
and children in low income families. NICE public health guidance.
NICE 2008 (B) Maternal and Child Nutrition. PH11 available at
http://publications.nice.org.uk/maternal-and-child-nutritionph11/introduction
The principal guideline developer was Ms. Fiona Dunlevy (Coombe Women and
Infants University Hospital).
The guideline was peer-reviewed by: Ms Laura Harrington (Rotunda Hospital),
Ms Sinead Curran (National Maternity Hospital), Ms Sinad N Bhriain (Food
Safety Authority Ireland), Dr. Ciara McGowan (St. James Hospital), Ms Ursula
O'Dwyer (Health Promotion Department), Dr. Sharon Cooley (Rotunda hospital),
Ms. Triona Cowman (Coombe Women and Infants University Hospital), Dr. Liz
Dunn (Wexford Regional hospital), Dr Emma Kilgarriff (General Practitioner), Ms.
Aoife O' Gorman (St. James Hospital), Dr Brian Cleary (Coombe Women and
Infants University Hospital).
Finally, the guideline was reviewed and endorsed by the Programmes Clinical
Advisory Group and National Working Party.
4. Clinical Guidelines
4.1 Weight Gain
It is advisable that all women should have their BMI calculated at the first
antenatal visit, ideally in the first trimester (Institute of Obstetricians and
Gynaecologists et al, 2011).
Anthropometric measurements taken during
pregnancy should be used to evaluate potential physiological stress and identify
those who would benefit from nutritional intervention (World Health
Organisation, 1995). These measurements need to be taken early enough to
allow time for intervention. Weight can be affected by nutritional intake,
gestation, physiological stress and genetic factors and these should be taken into
consideration on assessment (World Health Organisation, 1995).
Women should have their height measured with their shoes off standing straight
using a wall-mounted metre-stick (to the nearest 0.1 cm). Their weight should
be measured wearing light clothing (to the nearest 0.1 kg), and the BMI
calculated.
Weight (Kg)
= BMI kg/m2
Height (m2)
Example:
Weight (Kg)
BMI kg/m2
Height (m2)
Weight = 63kg
Height = 1.6 m
63
1.62
63
= 21 kg/m2
Therefore normal weight
BMI is a surrogate marker of adiposity and does not measure adipose tissue
directly. As a result, it has limitations and provides no information on fat
distribution (Fattah et al, 2010; Prentice and Jebb, 2001). Self-reporting of
height and weight has been shown to be unreliable (Fattah et al, 2010);
8
therefore it is essential to check maternal weight and height at an antenatal

booking visit. Although it is recognised that BMI is not an ideal anthropometric
measurement it offers an affordable and safe guide to estimate a womens
weight category, which, is essential in future screening for diabetes and preeclampsia. Short stature and low weight have been associated with small for
gestational age, risk for caesarean section and in intra uterine growth
retardation (WHO,1995), while overweight and obesity increases risks of
complications in delivery guideline on maternal obesity (Institute of Obstetrics
and Gynaecologists 2011) and of chronic diseases in the infant (Barker, 2012).
Therefore, BMI checks at booking visit should be used as a screening mechanism
for those at increased risk (WHO, 1995).
There is no international consensus on appropriate weight gain per weight
category in pregnancy (Alavi et al, 2013, NICE 2010). However, in the absence
of such data the institute of medicine guidelines (2009) which are based on
observational data in the USA are widely used as a guide (see Appendix 2) and
evidence suggests that women who gain weight within these ranges have better
outcomes (Siega-Riz et al, 2009).
Women who are overweight or obese at booking tend to gain weight at a slower
rate than normal weight women (Farah et al, 2011). Weight loss in pregnancy is
not recommended (Arendras et al, 2008) preferably pre-pregnancy and
postnatal intervention on weight loss is likely to be the most appropriate target
time for treatment of obesity, as women who restrict their intake during
pregnancy are at risk of insufficient nutrient intake without a dietetic
consultation (HSE, 2011). Maternal obesity rather than the rate of gestational
weight gain is associated with increased risk of pregnancy complications
(ODwyer et al, 2013). Weight loss in the postnatal period before subsequent
pregnancies is an effective strategy for improved outcomes (Karl et al, 2006),
women from lower socioeconomic backgrounds are at higher risk of developing
obesity postnatally and should be targeted for weight loss interventions (Turner
and Layte, 2013).
It is important that information about obesity and its risks are communicated in
an informative, yet sensitive manner (Schmied et al, 2010; Furber and
McGowan, 2011). Women who are underweight are also likely to be sensitive
about their weight and sensitivity is equally important with this patient group.
Underweight women should be encouraged to meet requirements during
pregnancy and may benefit from a dietetic consultation to ensure these needs
are met.
When assessing weight gain in pregnancy, clinical judgment should be used to
assess other clinically relevant causes for change in weight for example oedema,
as well as fetal growth assessment before recommending modifications to
change the gestational weight (Rasmussen and Yaktine, 2009). Table 1 shows
the composition of biological components contributing to weight gain in
pregnancy (American College of Obstetricians and Gynecologists, 2000).
Ideally women who are underweight, overweight or obese should be
seen for pre-pregnancy dietary counseling in the community to optimise
weight prior to conception and therefore reduce associated risks during
pregnancy.
9
Distribution of weight gain in pregnancy

Approximate
(normal BMI)
Baby
3.4 kg
Placenta
0.7 kg
Amniotic fluid
0.9 kg
weight
gain
Mother
Breasts
0.9 kg
Uterus
0.9 kg
Body fluids
1.8 kg
Blood
1.8 kg
Stores of fat, protein and other 3.2 kg

nutrients
TOTAL
13.6 kg
Table 1: Adapted from: Planning Your Pregnancy and Birth, 3rd ed. American
College of Obstetricians and Gynecologists, 2000.
4.2 Nutrient Overview

Pregnant women should be advised to follow the recommendations of the food
pyramid. Irish studies have shown that less than 50% of pregnant women meet
the recommendations for each individual group of the food pyramid (ONeill et
al, 2011) and less than 1% of the national population meet requirements for all
groups (SLAN, 2008). Within the Irish population, there is over consumption of
foods at the top of the food pyramid where guidelines recommend 1 or less
servings a day (SLAN, 2008). This is matched with under consumption of foods
at the lower end of the food pyramid, with the average intake of fruit and
vegetables being much lower than the recommendations (IUNA, 2011).
The recommendations for nutritional intake during pregnancy remain largely the
same as outside of pregnancy with a few exceptions:
Women should be advised to take a daily supplement of 400 micrograms

(400g/0.4mg) folic acid at least 4 weeks prior to conception and during
the first 12 weeks of pregnancy.
Iron, calcium, vitamin D and long chain omega-3 polyunsaturated fatty
acids are particularly important nutrients throughout pregnancy.
The Food Pyramid guidelines are summarised below:
Starchy carbohydrates, such as whole grains and fibre rich foods including
breads, cereals potatoes, pasta and rice, 6 or more servings a day from
10
this group; Where one serving is 1 bowl of cereal, 1 slice of bread or 1

medium potato
Fruit and vegetables, at least 5 or more servings a day; 1 serving is 1
medium sized fruit e.g. 1 apple or 3 dessert spoons of vegetables.
Dairy Foods which includes milk, cheese and yoghurt, 3 servings a day
from this group; 1 serving is 125g yoghurt, 25g of cheese or 200ml milk.
Protein Foods including Meat, poultry, fish, eggs or legumes, at least 2
servings a day: Where one portion is 50-75g (2 -3oz) cooked meat, 100g
(4oz) fish, 2 eggs or 6 dessert spoons beans.
Fats and oils are needed in small amounts , limit to 2 portions a day: one
portion is 1 heaped teaspoon of spread. In addition 1 teaspoon per person
of oil can be added in cooking (rapeseed oil or olive oil).
Foods high in Fat and sugar should be avoided.
11
The healthy eating guidelines including the Food Pyramid, your guide to health
eating using the Food Pyramid can be ordered through the Department of
Health, health promotion website:
http://www.healthpromotion.ie/
12
4.3 Macronutrients
4.3.1 Energy
Adequate energy intake is essential to promote optimal growth of the fetus while
providing adequate energy for the mother.
Inadequate maternal energy intake will result in reduced maternal weight
during pregnancy, which in turn may result in restricted fetal growth and
infant development (Rasmussen and Habicht, 2010). Inadequate weight
during pregnancy is associated with small for gestational age infants
preterm delivery (Scholl, 2008).
gain
later
gain
and
Conversely, excessive maternal weight during pregnancy is associated with large

for gestational age infants, macrosomia, a higher caesarean section risk, in
addition to a greater incidence of neonatal infection, hypoglycaemia and
respiratory distress (Siega-Riz et al, 2009). Additionally, large for gestational
age infants are at a greater risk of developing childhood obesity, and hence a
spectrum of metabolic complications in childhood and later life (Koletzko et al,
2012). Furthermore, rates of miscarriage are higher in obese women, as is
gestational diabetes, hypertension and deep vein thrombosis (Institute of
Obstetricians and Gynecologists et al, 2011). Obese women are also at risk of
small for gestational age babies in particular if they have other complications
such as hypertension.
Energy requirements in pregnancy vary widely between individuals it has been
estimated that women will require an additional 5% in the first trimester, 10% in
the second trimester and 25% in the third trimester. Based on a well-nourished
woman with a normal BMI this intake equates to an additional 70kcal per day in
the 1st trimester, 260 kcal per day in the second and 500kcal a day in the third
trimester (EFSA, 2013).
When choosing foods to increase energy intake, focus should be given to foods
which are rich in essential vitamins and minerals such as milk and milk products,
high fibre foods, lean red meat, omega-3-rich fish and fruits and vegetables
(FSAI, 2011). The mother should be encouraged to consume a diet which will
meet all her recommended nutritional intakes, rather than focusing on energy
intake alone. Overweight or obese women should be encouraged to replace
energy dense snacks with nutritious snacks.
4.3.2 Protein
Protein is essential in the development of a healthy baby as it forms the
structural basis for all new cells and tissues in the mother and fetus. It is
important to ensure the adequate balance of protein to energy as high protein
alone can cause harm to the fetus (Ota et al, 2012) and protein deficiency can
result in thin babies (Godfrey et al, 1997). Balanced intake of energy and protein
seems to improve fetal growth (Ota et al, 2012). However, evidence is emerging
on the relationship between the type of protein and fetal growth. Consumption of
processed meats (such as sausage, burgers and chicken nuggets) increases the
13
risk of small for gestational age babies (Knudsen et al, 2008) while fish and eggs
seem to reduce the risk (Ricci et al, 2010). Choosing foods high in fat, salt and
sugar, seems to further increase risk of small for gestational age baby
(Thompson et al, 2010).
Most women will meet their requirements for protein as the typical population
intakes are adequate for pregnancy (ONeill et al, 2011) with two servings of
protein a day.
Particular attention should be paid to women who are at risk of inadequate
protein intake or suboptimal protein choices. Women who have experienced
nausea or vomiting of pregnancy are likely to have reduced their intake of
protein rich foods due to aversions resulting from vomiting in early pregnancy.
Vegetarian women should be encouraged to consume adequate protein sources
during pregnancy by increasing their intake of foods rich in protein including
beans, lentils, chick peas, tofu, dairy products and eggs. Vegetarian women
should be advised on the importance of adequate protein sources to ensure
optimal intake of essential amino acids, for example combining cereals and
legumes in a meal. The adequacy of dietary iron intake should also be addressed
within this group. Women following a vegan diet may need dietetic review to
ensure nutritional adequacy.
Women from lower socioeconomic groups are at higher risk of inadequate
protein intake due to the associated costs. They are also more likely to choose
less expensive processed foods which would put them at risk of small for
gestational age babies. If purchased in a multiple supermarket, a healthy diet
costs 15-30% of the household budget for a family of 4 living on social welfare
(Healthy Food for All, 2009). Food poverty in Ireland is on the increase with 10%
of the population experiencing food poverty in 2010, this would indicate that
people cant afford a meal with meat or vegetarian alternative every second day
(Carney and Maitre, 2012). Health-care professionals should take this into
consideration when advising women and discuss less expensive ways of
incorporating protein into the diet such as the use of eggs, beans or lentils in
cooking.
The meat, fish, eggs and alternatives shelf of the food pyramid includes foods
that are rich sources of protein in the diet. Pregnant women should be
encouraged to consume two portions of protein rich foods a day and avoid
processed versions such as sausages, luncheon meats etc.
4.3.3 Fats
Dietary fat is an important energy source, and provides and aids in the
absorption of fat soluble vitamins. However, high fat diets should be avoided
during pregnancy due to the risk of excessive weight gain (FSAI, 2011).
Long chain Omega 3 polyunsaturated fatty acids (PUFA)
Docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are two important
long chain omega-3 PUFA. DHA in particular is important for the developing
fetus and there is evidence to support DHA consumption in pregnancy. DHA has
14
been linked to improved retinal development and forms an important part in the
grey matter of the brain tissue (Koletzko et al, 2007). Ongoing research
suggests that DHA could play a role in reducing risk of maternal depression,
improving mood and reducing risk of allergy in infants. Maternal fish
consumption during pregnancy has been positively associated with cognitive and
visual abilities in the offspring but research into maternal supplementation is
inconclusive as yet (Gould et al, 2013).
The European Food Safety Authority (EFSA) recommends that all pregnant
women should consume an additional 700-1400mg/week of DHA (EFSA, 2010).
This is in addition to the requirement of 1750mg/week combined EPA and DHA.
This increased intake can be achieved by consuming 1-2 portions of oil-rich fish
per week (FSAI, 2011). The best sources of DHA are trout, salmon, mackerel,
artic char and sardines (FSAI, 2011).
Certain types of fish can be a source of environmental contaminants such as
methylmercury. High levels of methylmercury may be harmful to the developing
fetus. Therefore pregnant women should avoid the consumption of marlin,
shark, ray and swordfish and limit consumption of tuna to one serving of fresh
tuna (150g), or two 240g cans of tinned tuna per week.
4.4 Micronutrients
4.4.1 Folate/ Folic acid
Folate is a B vitamin which is referred to as folic acid in the synthetic form. A
daily supplement of 400 micrograms (400g/0.4mg) folic acid as recommended
prior to conception and for the first 12 weeks of pregnancy, has been shown to
help prevent neural tube defects (NTDs) (FSAI, 2006). Women who have a
family history of NTDs or pre-existing diabetes should be provided with a
prescription of a higher dose of folic acid prior to conception through 12 weeks
gestation (HSE 2010). There is evidence to support the supplementation of
obese women with a higher dose of folic acid (CMACE, 2010; Institute of
Obstetricians and Gynaecologists et al, 2011) as the incidence of congenital
malformations, including NTDs, are higher in obese women compared with
normal women (Rasmussen et al, 2008). Currently the HSE recommends that
these women are prescribed a higher dose folic acid to be given with prescription
(4000micrograms / 4 milligrams) (HSE, 2010). Care should be taken when
placing women on this higher dose of folic acid due to increased risk of colorectal
adenomas with prolonged high dose intake (Cole BF et al, 2007; Fife J et al,
2009). For women taking anti-seizure medication the requirement for folic acid
may be different and they should be advised to consult their doctor (FSAI,
2011).
Supplemental folic acid can stop at 12 weeks gestation as the neural tube will
have closed and the window of opportunity for prevention of NTD will have
passed but the role of folate in red blood cell manufacture and in cell replication
continues to be of importance. Thus, women should continue to eat foods rich in
folate and folic acid throughout their pregnancy. These include green leafy
15
vegetables, citrus fruit, whole grains, legumes and foods fortified with folic acid
such as breads and cereals.
4.4.2 Iron
The developing fetus requires a large red blood cell mass to provide sufficient
oxygen for development and growth. There is a positive association with its
intake and birth weight (Alwan et al, 2011). Iron requirements increase
progressively after 25 weeks to combat the lower oxygen environment in the
womb (Dewey and Chaparro, 2007). Late cord clamping at delivery can reduce
the risk of infantile anaemia (Chaparro et al, 2006). However, it remains vital
that the iron intakes of the mother are sufficient throughout pregnancy to meet
the increased requirement for fetal growth (Health Canada, 2009), while
maintaining adequate maternal stores. Appropriate use of supplementation and
iron rich diet has the potential of reducing incidence of anaemia in pregnancy
and subsequent adverse outcomes (Barroso et al, 2011) therefore the threshold
for iron supplementation in pregnancy should be low.
The Survey of Lifestyle Attitudes and Nutrition reveals that a significant
proportion of women of reproductive age do not meet the daily requirement for
iron (SLN, 2007). This corresponds to research in pregnant women which
shows the majority are not reaching their requirements for iron during
pregnancy (McGowan and McAuliffe, 2012). There are two types of iron in the
diet, haem iron and non-haem iron. Haem iron is more readily absorbed. While
non-haem iron is more difficult to absorb, absorption can be assisted with
concomitant intake of vitamin C from fruit, fruit juice and certain vegetables.
Foods that contain tannins such as tea should be avoided at meal times as these
can inhibit the absorption of iron from the diet (FSAI, 2011). See appendix 2 for
a list of haem iron and non-haem iron food sources. Many Iron rich foods can be
expensive and therefore women form lower socioeconomic groups are at higher
risk of inadequate intake.
Women suspected of iron deficiency should have a full blood count (FBC) and if
possible serum ferritin checked. Symptoms of iron deficiency are similar to some
common problems of pregnancy such as fatigue. If there is evidence of iron
deficiency, the treatment is oral iron supplementation (NICE, 2008). Iron ferrous
contained within some supplements, can cause unpleasant gastrointestinal (GI)
side effects, impair mineral absorption, and increase risk of haemoconcentration
(Zhou et al, 2009). Slow-release iron preparations or split doses may alleviate
these symptoms. Other dietary tips can also help GI symptoms such as
increased fibre and fluid intake. It is important to ensure compliance with the
recommended treatment as women suffering from GI symptoms may avoid the
supplement, therefore variations of iron preparations should be explored.
Intermittent or lower dose iron preparations seem to be sufficient in preventing
anaemia without unpleasant GI symptoms (Pena-Rosas, 2012), indeed a
supplement containing 16-20mg of iron should be effective in the healthy
population (Health Canada, 2009). Women with low haemoglobin FBC or serum
ferritin will require higher dose supplements in keeping with doses recommended
for Iron deficiency anaemia.
Note: Despite its high iron content, it is important to advise pregnant woman
that liver is not recommended due to its high vitamin A content.
16
4.4.3 Calcium
Calcium has a key role to play in the development of healthy bones and teeth as
well as extra-cellular fluid, muscle, and other tissues. It is also involved in
vascular contractions and vasodilation, muscle contractions, neural transmission,
and glandular secretion. Adequate dietary calcium intake before and during early
pregnancy may reduce the risk or severity of pre-eclampsia (Hofmeyr, 2007)
and therefore adequate dietary intake should be encouraged.
During pregnancy women should be advised to consume 3 portions of dairy or
calcium-fortified alternatives daily (FSAI, 2011). Adolescent pregnant mothers
may require additional calcium which is best achieved with 2 additional portions
of dairy (5 total) per day (Chan et al, 2006).
A portion is one glass of milk (200 ml), one pot of yoghurt (~125 ml) or a
matchbox-sized piece of cheddar cheese (28g). Whole milk, low-fat and
skimmed milk all contain relatively similar levels of calcium and fortified milk is
typically fortified with extra calcium and vitamin D. Advise women to choose
milk and yoghurt more often than cheese.
4.4.4 Vitamin D
Vitamin D is a fat-soluble vitamin essential in the absorption of calcium and is
linked to prevention of autoimmune diseases (Fronczak et al, 2003; Hypponen
et al 2001). Adequate provision of vitamin D has been found, in ecological,
cross-sectional and observational studies, to be associated with reduction in the
risk of many types of cancer, cardiovascular diseases (CVDs), autoimmune
diseases, diabetes mellitus types 1 and 2, neurological disorders and several
bacterial and viral infections (FSAI, 2007). Vitamin D can also reduce risk of
adverse pregnancy outcomes including pre-eclampsia in addition to the classical
bone disorders of rickets and osteomalacia.
Vitamin D is found naturally in few foods; dietary sources of this fat soluble
vitamin include flesh of fatty fish, some fish liver oils (however fish liver oil
should be avoided in pregnancy), and eggs from hens fed vitamin D. Foods
fortified with vitamin D such as margarine, milk and cereals are a good source of
vitamin D in the diet. Although vitamin D can be synthesized in skin, above
latitudes of approximately 40N such as Ireland, vitamin D3 cannot be made in
the skin from October to March. The UV light that is able to promote Vitamin D
synthesis cannot penetrate the atmosphere during this time. Furthermore, sun
exposure may increase the risk of melanoma, and so advising sun exposure is
not an effective public health strategy to combat low vitamin D levels.
Recent studies show that the average intake of vitamin D in the Irish population
is well below the recommended intake (SLAN, 2007; IUNA, 2011). It is of
particular concern that suboptimal intakes and low serum vitamin D levels have
also been reported in cohorts of pregnant women in Dublin (McGowan et al,
2011) Cork (ORiordan et al, 2008), and Belfast (Holmes et al, 2009). In order to
meet nutritional requirements for vitamin D women should be encouraged to
take oily fish once or twice a week (FSAI, 2011). However, the consumption of
vitamin D rich foods, such as oily fish is not widespread and a vitamin D
supplement is likely to be needed by most women during pregnancy to meet
17
their requirements. Pregnant women should be advised to take a pregnancy

suitable supplement containing 5g of vitamin D (5 micrograms/ 200IU) (FSAI
2011). This recommendation is due to be reviewed by an expert working group
for the Irish population. The American College of Obstetrics and Gynaecologist
recommend 15g (15 micrograms/600IU) a day (ACOG, 2011) and the UK
recommendation is 10g (10 micrograms/ 400IU) a day during pregnancy and
lactation (NICE 2008, B). Of note, the majority of over-the-counter antenatal
multivitamins contain 10 g (10 micrograms/ 400IU) of vitamin D, therefore if a
woman chooses to take a pregnancy multivitamin she will not require additional
vitamin D supplementation. If there is a history of rickets in a sibling or a known
maternal vitamin D deficiency, a higher treatment dose is warranted as the
neonatal serum Vitamin D will be 60% of the maternal level, and both adequate
maternal and neonatal serum levels are positively associated with bone health in
childhood and later life . The number of trials and outcomes reported are too
limited, and in general are of low quality, to draw conclusions on the usefulness
and safety of high levels of vitamin D supplementation as a part of routine
antenatal care. Further randomised trials are required to evaluate the role of
vitamin D supplementation in pregnancy (De-Regil et al, 2012).
4.4.5 Iodine
During pregnancy iodine requirements increase by 50% (Stagnaro-Green et al
2011), Iodine deficiency appears when the maternal thyriod gland cannot meet
the demand for increasing production of thyroid hormones (Obican et al 2012).
Research in Ireland has shown low serum levels of iodine are low in 23% of
women in winter months and 55% of women in the summer months (Nawoor et
al, 2006). It is suggested that maternal iodine deficiency can result in
hypothyroinaemia and elevated TSH in infants, which is associated with cognitive
and psychomotor deficits (Obican et al 2012). Supplementation of iodine may
decrease the risk of cognitive and psychomotor developmental delay (Trumpff et
al 2013). Dietary sources of iodine include seaweed, iodized salt, dairy products
and fish. The American Thyroid Association recommend that all pregnant women
should consume 220g (220 micrograms) of iodine daily (Stagnaro-Green et al
2011) while the WHO recommends an upper limit of 500 g (500 micrograms)
and the EFSA (2009) an upper limit of 600g/day (600 micrograms).
Currently there is no national guideline for the supplementation of iodine
although prenatal vitamins contain various amounts and women should be
recommended to increase foods containing iodine to meet requirements.
4.4.6 Supplementation
Folic acid supplementation is recommended prior to conception and during the
first 12 weeks of pregnancy. A daily supplement of 400 micrograms (400 g/
0.4mg) is recommended for all women. However, a higher dose administered
with prescription (containing 4000 micrograms/ 4 milligrams) should be given to
those with pre-existing diabetes, obesity and where there is previous delivery of
an infant with NTD or a family history of NTD.
The consumption of vitamin D rich foods, such as oily fish is not widespread and
a vitamin D supplement is likely to be needed by most women during pregnancy
18
to meet their requirements. Women should be advised to take a daily pregnancy

suitable supplement containing 5g (5 micrograms/ 200IU) of vitamin D.
Iron supplementation is recommended for women with a low serum ferritin or
those deemed at risk of developing iron deficiency anaemia. A low threshold for
checking iron status should be maintained during pregnancy due to associated
risks. Advice on avoidance of GI side effects should be given prior to
commencing supplementation to improve compliance.
If a supplement is deemed necessary in pregnancy women should be
encouraged to take a supplement which is specifically designed for pregnancy.
Women should avoid any over the counter supplements which are not pregnancy
specific.
4.5 Foods to Avoid

4.5.1 Toxicological substances
Caffeine
Excessive caffeine in pregnancy has been hypothesised to have teratogenic

effects and although not all human epidemiological studies and animal studies
support these claims (Brent et al, 2011) women should be advised to limit their
intake during pregnancy. Caffeine can be absorbed freely across the placenta,
but cannot be broken down by either the placenta or the fetus. Therefore,
maternal caffeine consumption is closely linked with placental and fetal caffeine
concentrations, and the fetus can be exposed to the effects of caffeine. Caffeine
is a mildly addictive stimulant which is found naturally occurring in foods and
drinks such as coffee, tea and cocoa (FSAI, 2011) Caffeine is also used as an
additive in soft drinks, energy drinks, some chewing gums and medications. It is
therefore possible that pregnant and lactating women may consume excessive
caffeine from multiple sources. Women are advised to limit caffeine to less than
200mg per day, which equates to 2-4 mugs of tea or 2 cups of coffee or 1000ml
cola or 500ml energy drink or 4 bars of chocolate. Caution should also be taken
when prescribing medications that contain caffeine.
Vitamin A
During pregnancy dietary intakes of vitamin A (retinol equivalent) greater than

7,000 micrograms may be teratogenic leading to an increased risk of congenital
malformations. Therefore, supplements containing pre-formed vitamin A, should
be avoided. Due to the high levels of vitamin A contained in liver and liver
products, e.g. cod liver oil, these foods should also be avoided (NICE, 2008).
Beta carotene is a precursor of Vitamin A (retinol) and is not harmful in
pregnancy. Many food supplements will contain beta carotene as their source of
Vitamin A (Azais-Braesco and Pascal, 2007).
19
4.5.2 Food borne infections

Safe food preparation and hygiene practices are important at all stages of life in
order to prevent potentially harmful food-borne illnesses. This is particularly
important during pregnancy as some bacteria and parasites can reach the
developing infant causing severe illness in the neonate, miscarriage or stillbirth.
These include Listeria, Salmonella and Toxoplasmosis. To prevent food-borne
illness, women should be advised to:
Ensure eggs are cooked thoroughly, avoid soft eggs or raw eggs e.g. in
mousse.
Avoid un-pasteurised milk and any cheese or yoghurt made with unpasteurised milks.
Avoid mould ripened cheese e.g. Camembert, Danish Blue, Brie, Stilton.
Ensure all meat, fish and poultry is cooked throughout. Avoid smoked fish
such as smoked salmon, cured and smoked meats e.g. salami.
Wash all raw ingredients such as fruits, vegetables and pre-packed salads
very well before eating.
Keep raw and cooked meats separate, and use different knives, chopping
boards and other kitchen utensils when preparing these foods to avoid
cross-contamination.
Ensure refrigerator temperature is below 5C and put food in the
refrigerator as quickly as possible. Freezer temperature should be below 18C.
Always wear gloves when gardening or changing cat litter, and always
wash hands very well after these activities or handling animals or pets.
For more information see the safefood website
(http://www.safefood.eu/Home.aspx) and FSAI 2011.
5. Specific diets
Patients on therapeutic diets should be given the opportunity to review their
intake with a dietitian these include patients with coeliac disease, diabetes,
phenylketonuria and anaemia of pregnancy. Women with chronic disease will
ideally have had dietetic input as part of their preconception preparation and
continue to have input from their multidisciplinary team as part of their obstetric
management.
5.2 Allergies
There is currently insufficient evidence to recommend that mothers of infants
who are at risk of developing an allergy should avoid potentially allergenic foods
during pregnancy unless she herself is allergic to a certain food.
6. Hospital Equipment and Facilities

All women should have a weight and height measurement taken at their booking
antenatal visit. The centre should ensure equipment is available in a discrete
area and calibrated as required to accurately record measurements.
20
7. Provision of information on best practice for infant

feeding
It is the responsibility of all healthcare professionals to promote best practice for
infant feeding:
Information and support around breastfeeding should be given ante-natally

or even before, as it has been shown that many women make the decision on
whether or not they will breastfeed before the birth of their infant (FSAI,
2011). Pregnant women should be educated during this time on the many
benefits breastfeeding offers the mother and her infant including the health
benefits in both short-term and throughout later life.
Pregnant women should be advised on the correct time to wean an infant

onto solid food, which provides a guide thus reducing the risk of early and
inappropriate introduction of solid foods (Dunlevy, 2010)
21
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9. Implementation Strategy
Distribution of guideline to all members of the Institute and to all

maternity units.
Implementation through HSE Obstetrics and Gynaecology programme
local implementation boards.
Distribution to other interested parties and professional bodies.
29
10. Key Performance Indicators
Proportion of women with an accurate weight and height assessment in

early pregnancy
Proportion of pregnant women receiving advice on appropriate food
pyramid choices to meet nutritional requirements.
Proportion of women advised appropriately on folic acid supplementation.
Adherence to vitamin D supplements recommendation.
Appropriate advice on avoidance of toxicological and potential food borne
diseases in pregnancy.
11. Qualifying Statement

These guidelines have been prepared to promote and facilitate standardisation
and consistency of practice, using a multidisciplinary approach. Clinical material
offered in this guideline does not replace or remove clinical judgment or the
professional care and duty necessary for each pregnant woman. Clinical care
carried out in accordance with this guideline should be provided within the
context of locally available resources and expertise.
This Guideline does not address all elements of standard practice and assumes
that individual clinicians are responsible for:
Discussing care with women in an environment that is appropriate and

which enables respectful confidential discussion.
Advising women of their choices and ensure informed consent is obtained.
Meeting all legislative requirements and maintaining standards of
professional conduct.
Applying standard precautions and additional precautions, as necessary,
when delivering care.
Documenting all care in accordance with local and mandatory
requirements.
30
Appendix 1 - Useful websites

Food Safety Authority of Ireland website:
http://www.fsai.ie/
Food Safety Authority of Ireland, Best Practice for Infant Feeding in Ireland,
2011:
www.fsai.ie/bestpracticeforinfantfeedinginireland.html
Food Safety Authority of Ireland, Scientific Recommendations for a National
Infant Feeding Policy, 2nd Edition, 2011:
www.fsai.ie/scientificrecommendationsforanationalinfantfeedingpolicy.html
Whats Up Mum website:
www.whatsupmum.ie
HSE Health Promotion website:
http://www.healthpromotion.ie/
Safefood website:
http://www.safefood.eu/
The Irish Nutrition and Dietetic Institute (INDI) website:
www.indi.ie
31
Appendix 2
Food Safety Authority Ireland (FSAI) 2011 Best Practice for infant feeding
in Ireland. Chapter 1 Nutrition and Lifestyle before and during pregnancy
32
A guide for healthcare professionals
chapter 1
Nutrition and Lifestyle
before and during
Pregnancy
33
1.1
Nutrition and Lifestyle before

Pregnancy
A healthy and balanced diet is important for good health

throughout all stages of life. A healthy and balanced diet
helps ensure that in the event of pregnancy, a woman of
childbearing age will be in good health throughout the
pregnancy and will be able to provide the unborn infant
with the nutrition needed to develop properly.
Women of childbearing age should aim to consume a
nutritionally adequate diet. Such a diet should contain foods
from the five main foods groups every day. A supplement of
400g folic acid should be taken daily to help prevent neural
tube defects (NTDs) in infants. Healthcare professionals
should provide information on:
Maintaining a healthy body weight
Not smoking/smoking cessation
The weekly alcohol limits for women

Women should be advised not to consume more than 11
units (approximately 110g alcohol) spread over a week.
A unit is a rough measure of the amount of drink that
will provide about 10g alcohol, e.g. pint beer (284ml),
pub measure of spirits (35.5ml), or a small glass of wine
(100ml).
The new Food Pyramid from Healthy Eating and Active Living
for Adults, Teenagers and Children over 5 years A Food Guide
for Health Professionals and Catering Services.
Healthy eating guidelines for women of

childbearing age
Enjoy a wide variety of foods from the five food groups

(See Food Pyramid below)
Pay attention to serving sizes - choose smaller portions

and add plenty of vegetables, salad and fruit.
Include wholemeal breads, cereals, potatoes, pasta and

rice to provide energy for a healthy weight.
Eat at least five servings of different coloured fruit and

vegetables every day.
Use low-fat varieties of milk, yoghurt and cheese - choose

milk and yoghurt more often than cheese.
Include lean meat, poultry and fish (oily is best) daily,

and remember that peas, beans and lentils are good
alternatives.
Use polyunsaturated and monounsaturated spreads

and oils sparingly reduced-fat spreads are best.
Healthy eating can be enjoyed without foods like

confectionery, savoury snacks, and biscuits these
foods are rich in calories, fat, sugar and salt and need
to be limited.
Drink plenty of water.
34
Healthy cooking practices
Grill, bake, steam or boil food instead of frying or deep

frying.
Prepare and store food safely.
Over half of all pregnancies in Ireland are

unplanned.
Limit salt intake - Use fruit to make tasty sauces for meat
and poultry, e.g. apple or cranberry sauce and flavour food
with pepper, herbs and spices, lemon juice, vinegar.
As such, it is important that healthcare professionals

recognise this vulnerability in women of childbearing
age, and tailor their health-related advice accordingly.
Vitamin D
Up to 70% of all neural tube defects can be

prevented by taking a 400g folic acid supplement
Vitamin D is needed for strong healthy bones and may protect

against heart disease and cancer. Most people do not get
enough vitamin D. Choosing oily fish one to two times a
week is the best way to get vitamin D. Taking a daily vitamin D
supplement is another way of getting vitamin D. The best
choice is to take a vitamin D supplement of 5g (200 IU) every
day.
for at least 4 weeks prior to conception and during

the first 12 weeks of pregnancy.
Active Living
What is the bottom line in terms of nutrition

and lifestyle before pregnancy?
Being active for adults means taking part in at least 30

minutes of moderate to vigorous activities such as walking,
running, cycling, swimming, Gaelic games, rugby, football,
basketball, or dancing, on at least 5 days a week.
1. Advice on healthy eating and lifestyle and how to maintain

a healthy weight should be provided to all women of
childbearing age.
This will help ensure that the mother provides the best
possible environment for her infant if she becomes
pregnant.
The importance of folic acid supplementation

before pregnancy
Folate is a B-vitamin found naturally in some foods such as
green leafy vegetables. Folic acid is the synthetic form of
folate which is used to fortify some foods such as breakfast
cereals and milk, and is found in some food supplements.
It is difficult to get the recommended amount of folate
from the diet alone. This is why a folic acid supplement is
recommended.
2. Women of childbearing age should be advised to take a

daily supplement of 400g folic acid to prevent NTDs.
This is especially important for at least 4 weeks prior to
conception and during the first 12 weeks of pregnancy.
3. Women who have given birth to an infant with a neural tube
defect should be prescribed a high-dose daily supplement
containing 4,000g (4mg) folic acid.
The neural tube becomes the brain and spinal cord in humans,
and is therefore essential to the correct development of the
nervous system. A sufficient level of folic acid is required to
ensure the neural tube closes correctly. Incorrect closure of
the neural tube causes NTDs in the infant.
NTDs, such as Spina Bifida, are severe abnormalities of the
brain and spine which can develop in a foetus between days 21
and 28 after conception. A woman may only begin to suspect
a pregnancy around this time. Therefore, sexually active
women of childbearing age should be advised to take a daily
supplement of 400g folic acid in preparation for a possible
unplanned pregnancy. This supplementation should continue
for the first 12 weeks of pregnancy.
Recent research in Ireland has shown that although most
pregnant women take folic acid supplements, many do
not take folic acid supplements in time to prevent NTDs.
Therefore, it is imperative that healthcare professionals
encourage all women of childbearing age to develop the habit
of taking a folic acid supplement daily.
Women who have had an infant with a NTD should be

prescribed a daily 4,000g (4mg) folic acid supplement
at least 4 weeks prior to conception and for the first 16
weeks of pregnancy to help prevent recurrence.
4. Dietary sources of folate are important.
In addition to taking a folic acid supplement, women
should also be advised to eat foods fortified with folic acid
(such as fortified breakfast cereals and fortified milk) and
high folate foods (such as green leafy vegetables).
Further Information
FSAI 2011, Scientific Recommendations for Healthy Eating

Guidelines in Ireland
www.fsai.ie
FSAI 2012, Healthy Eating and Active Living for Adults,

Teenagers and Children over 5 years A Food Guide for
Health Professionals and Catering Services
www.fsai.ie
INDI 2005, Planning a Pregnancy: Good Nutrition for

Preconception
www.indi.ie
35
1.2 Good Nutrition for a Healthy

Pregnancy
Healthy eating is important for pregnant women
A healthy and balanced diet during pregnancy helps to ensure
that:
Women have the nutrients needed for good health during

and after pregnancy, and;
Infants have the best possible environment in which to

grow and develop
The time an infant spends developing in the womb is critically

important and can influence health throughout adult life.
Evidence suggests that many diseases common in later life
such as heart disease and diabetes, may have their root in this
period of early development.
What is a healthy diet during pregnancy?
The importance of folic acid supplementation

during the first 12 weeks of pregnancy
Pregnant women should take a folic acid supplement of 400g
per day during the first 12 weeks of pregnancy to help prevent
NTDs in the infant. If a mother has previously had an infant
with an NTD, a supplement containing 4,000ug of folic acid is
required per day to help prevent recurrence. See page 5 for
further information on folic acid.
Foods rich in iron are important during

pregnancy
Why is iron important during pregnancy?
Iron is involved in the transport of oxygen to the developing
foetus and helps to protect the health of a pregnant woman.
A pregnant womans body adapts to absorb more iron from
the diet; however, it is still essential that there is sufficient iron
in the diet to support both the mother and the developing
foetus.
During pregnancy, a healthy and balanced diet can be

achieved by following the healthy eating guidelines for
women in Ireland (FSAI 2012, Healthy Eating and Active
Living for Adults, Teenagers and Children over 5 years A Food Guide for Health Professionals and Catering
Services). The 5 main food groups which provide the
nutrients needed for a healthy pregnancy are:
How can a pregnant woman get enough iron from her

diet?
Breads, cereals and potatoes choose

wholegrain and wholemeal more often
Dietary iron exists in haem and non-haem forms.
Fruit and vegetables choose at least 5 a day

and vary the types chosen
Milk and milk products choose low-fat milk

and yoghurt more often than cheese
Meat, fish, chicken and alternatives choose

lean cuts of meat
Fats and oils use sparingly
Pregnant women need to consume a total of 15mg of iron

from their meals every day. Pregnant women should aim to eat
iron-rich foods twice daily. Examples of suitable food sources
of iron are found in Table 1.
Haem iron
Haem iron is more easily absorbed by the body and the best
source is red meat such as beef, lamb, mutton and pork.
Despite its high iron content, it is important to note that liver
is not recommended for pregnant women due to its high
vitamin A content. High maternal vitamin A intake during
pregnancy can be harmful to the developing foetus.
Certain nutrients are particularly important to help

protect a mothers health and to promote the healthy
development of an infant. To include these nutrients
in the diet, pregnant women should prioritise the
consumption of foods rich in iron, calcium, vitamin
D, and long chain omega-3 polyunsatura ted fatty
acids. Each of these nutrients is discussed in detail
on the following pages.
36
Non-haem iron
Non-haem iron is less well absorbed by the body. It is found in
eggs, green leafy vegetables, pulses and foods fortified with
iron.
What foods and uids increase the amount of iron

absorbed by the body?
Consuming a source of vitamin C with a meal containing
non-haem iron will improve the amount of iron absorbed by
the body. Sources of vitamin C include fresh fruits (such as
oranges, lemons, kiwis, strawberries and limes), fruit juices

made from these and fresh vegetables (such as broccoli,
peppers, cauliflower and kale).
What foods and uids decrease the amount of iron

absorbed by the body?
Consuming a source of tannins or phytates with a meal
containing iron will decrease the amount of iron absorbed
by the body. Sources of tannins include tea and coffee, and
sources of phytates include very high-fibre foods such as bran
and high-fibre cereals.
Table 1. Amount of Iron in Commonly Eaten Foods

Foods rich in more
easily absorbed
HAEM IRON
Serving
size
(g)
Iron
content
(mg)
RECOMMENDED RED MEAT
Average portion* of lean beef
120
3.2
Average portion* of lean beef

mince (stewed)
120
2.8
Average portion* of lean lamb

cutlets
120
2.5
Average portion* of pork chops
120
1.6
120
1.3
Foods rich in less

easily absorbed
NON-HAEM IRON
Serving
size
(g)
Iron
content
(mg)
1 cup** of fortified breakfast

cereal
30
2.4 4.2
1 small can of baked beans
140
1.9
1 cup** of boiled spinach
90
1.4
1 boiled egg
50
1 slice of wholemeal bread
36
0.9
1 cup** of boiled broccoli
85
0.9
cup of dried fruit
25
0.6
POULTRY
Average* chicken breast
See below: Portion Size Reference Guide - Palm of hand * and 200ml
disposable cup**
FISH
1 small tin of sardines

(canned in brine)
70
1.6
1 small tin of salmon
70
0.4
Average portion* of cod
120
0.5
60
12
PORTION SIZE REFERENCE GUIDE
OTHER
2 small slices of black pudding
This is a
reminder call
from your body...
IRON, VITAMIN D
and FOLIC ACID
are important for a
healthy pregnancy!
Palm of the hand*

The width and depth of your
palm (without fingers and
thumb) shows how much meat,
poultry or fish you need in a
day. Most of this can be used
for your main meal, with the
remainder for your light meal.
200ml Disposable Cup**

Use a disposable plastic cup to
guide portion sizes of milk,
milk puddings, cereals, cooked
pasta and rice, and even
vegetables, salad and fruit.
37
What about iron supplementation during pregnancy?

Pregnant women can find it difficult to meet their iron
requirements from diet alone, and in such cases, an
iron supplement may be needed. However, women can
experience uncomfortable gastrointestinal side effects such
as constipation when they are taking iron supplements. The
healthcare professional leading the care of the pregnancy
should advise accordingly.
Foods which contain calcium in a form that is less easily

absorbed by the body can be included as part of a varied
diet, but should not be relied upon to provide all the calcium a
pregnant woman needs. These include foods such as spinach,
sweet potatoes, rhubarb, beans, unleavened bread, seeds and
nuts.
Foods such as milk, milk-based products, and

soy-based products contain calcium in a form
that is easily absorbed by the body.
Haemochromatosis
Celtic populations such as the Irish population are
more prone to the iron overload disorder known as
haemochromatosis compared with other populations.
Individuals with haemochromatosis should not
consume large amounts of dietary iron and should
avoid iron supplements. Therefore, the family history
of haemochromatosis should be determined before
advising a woman about taking iron supplements.
Foods rich in calcium are important during

pregnancy
Why is calcium important during pregnancy?
Calcium is necessary to protect the bone health of the
mother and to provide the developing foetus with the calcium
needed for the healthy development of their skeleton.
Although the requirement for calcium does not increase
during pregnancy (because of pregnancy induced adaptations
to maternal calcium homeostasis), many women do not reach
the recommended daily intake.
Pregnant adult women require 1,000mg calcium

every day. Pregnant teenage girls require 1,300mg
calcium every day.
How can a pregnant woman get enough calcium

from her diet?
Milk and milk-based products are excellent sources of
calcium. To achieve the recommended daily intake of
1,000mg calcium, pregnant adult women should consume
at least three portions of milk or milk-based products (Table
2) every day. Consuming products fortified with calcium will
contribute to this recommended daily intake.
For lactose intolerant pregnant women or those who avoid
dairy foods, soy-based products fortified with calcium should
be included in the diet.
These foods should be prioritised for their calcium

content and included in the daily diet.
Table 2. Amount of Calcium in Commonly Eaten

Foods
Calcium-containing foods
Serving
size
(g)
Calcium
content
(mg)
1 tin of sardines (canned in oil,

drained)
70
350
1 pot of yoghurt
125
260
Average portion* of calcium

fortified set tofu
120
300
1 cup** of milk pudding with

skimmed milk
200
260
1 pot of fortified soy yoghurt
125
208
1 matchbox size piece

of cheddar cheese
30
220
1 cup** of rice pudding

with skimmed milk
200
170
1 pot of unfortified soy yoghurt
125
Trace
Calcium-containing fluids
Serving
size
(ml)
Calcium
content
(mg)
1 cup** of fortified low-fat milk
200
332
1 cup** of whole milk
200
240
1 cup** of semi-skimmed milk
200
240
1 cup** of skimmed milk
200
240
1 cup** of fortified soy milk
200
178
See page 7: Portion Size Reference Guide - Palm of hand* and 200ml
disposable cup**
38
High intakes of calcium can reduce the absorption of other

essential minerals such as iron. Therefore, it is important to
encourage women to meet, but not exceed, their calcium
requirements. Calcium supplements should only be advised
where there is a clear need.
The body can absorb calcium best from a calcium supplement
when:
It is broken down
Taken with a meal
The dose is 500mg calcium or less and
It is not taken with an iron supplement
Foods rich in vitamin D are important during

pregnancy
Why is vitamin D important during pregnancy?
Vitamin D is important during pregnancy since the vitamin
D intake and stores of a mother determine her developing
foetuss stores of vitamin D at birth. Vitamin D is needed to
help absorb calcium in the body and therefore is essential
for good bone health. Low levels of vitamin D have also been
linked with increased risk of heart disease, diabetes and the
metabolic syndrome.
Fish such as canned sardines have small edible

bones which are a rich source of calcium.
Vitamin D is manufactured when the skin is exposed to

ultraviolet (UV) light from the suns rays. However, in countries
above a latitude of 40N such as Ireland, vitamin D3 cannot
be made in the skin from October to March because the UV
light (of the wavelength) that is able to promote vitamin D
synthesis cannot penetrate the atmosphere during this time.
What about calcium supplementation during

pregnancy?
Pregnant adult women require 10g (400 IU) vitamin D every

day.
Pregnant women should be encouraged to meet

recommended intakes of calcium through the diet.
However, for women who dont like milk or milk-based
products, who are vegan, lactose intolerant, those who
do not include calcium enriched soy or non dairy foods, or
who find it difficult to consume enough calcium rich foods
in their daily diet, a calcium supplement may be needed.
How can a pregnant woman get enough vitamin D from

her diet?
Vitamin D is found naturally in only a few foods, including
oily fish, some fish liver oils, some fortified cereals and
fortified milks.
39
Table 3. Amount of Vitamin D in Commonly

Eaten Foods
Vitamin D-containing
foods
Serving
size
(g)
Vitamin D
content
(g)
Average portion* herring, grilled 120
13.1
Average portion* mackerel,

grilled
120
10.5
70
9.1
1 small tin of sardines

(canned in oil or tomato sauce)
70
5.6
Average portion* of salmon

steak, grilled
120
8.4
1 small tin of tuna

(canned in oil or brine)
70
2.3
1 egg, boiled
50
1 single portion pack of fortified

margarine***
10
0.8
Vitamin D-containing fluids
Serving
size
(ml)
Vitamin D
content
(g)
1 cup** of fortified milk
200
2.0
1 cup** of Supermilk
(whole and low-fat)
200
4.0
Limit tuna intake to one fresh tuna steak (150g) or two 240g cans of tinned
tuna per week during pregnancy due to mercury content
disposable cup**
See page 11: Portion Size Reference Guide - Portion pack***
While liver contains vitamin D, it should not

be consumed by pregnant women because it
contains high levels of vitamin A.
See page 11, Vitamin A during pregnancy, for further
information.
One of the richest sources of omega-3 fatty

acids in the diet is oily sh, examples of which
include salmon, mackerel, herring, sardines,
pilchard s, kippers and trout.
What about vitamin D supplementation during

pregnancy?
Women should be encouraged to include vitamin D rich foods
such as oily fish in their diet to meet requirements. However,
if a woman does not include these sources in her diet and
is considering taking a supplement, a low dose supplement
containing 5ug of vitamin D3 per day should be advised.
WARNING!
If a woman is taking a pregnancy multivitamin supplement
she is already getting enough vitamin D. Women should
be advised not to double up by taking additional
supplements.
Foods rich in long chain omega-3

polyunsaturated fatty acids are important
during pregnancy
Why are long chain omega-3 polyunsaturated fatty
acids important during pregnancy?
Two important long chain omega-3 polyunsaturated fatty
acids are eicosapentaenoic acid (EPA) and docosahexaenoic
acid (DHA). These fatty acids play an important role in slowing
down blood clot formation and are protective against heart
disease in the mother. DHA in particular is thought to be
important for a developing foetus, since it is an essential
component of the brain, nervous system and retinas of
the eyes.
How can a pregnant woman get enough long chain

omega-3 polyunsaturated fatty acids from her diet?
The human body has a very limited ability to make these long
chain omega-3 fatty acids. Therefore, it is critical that these
fatty acids are included in the diet. The European Food Safety
Authority (EFSA) recommends that all pregnant women
consume an additional 700-1,400mg DHA per week. This is
recommended in addition to the requirement of 1,750mg
combined EPA and DHA per week.
Pregnant women can achieve this recommendation for
increased DHA intake by consuming 1-2 portions of oily fish
per week (Table 4).
For vegetarians, or those who do not eat fish, sources of
alpha-linolenic acid (ALA) can be included in the diet, e.g.
some vegetable foods such linseeds, rapeseed oil and
walnuts. A small proportion of ALA can be converted by the
body to EPA and, to a lesser extent, DHA. Because only a
small amount of ALA is converted to EPA and DHA, oily fish is
very valuable in the diet. Apart from oily fish, the only natural
sources of EPA and DHA are human breast milk and cultivated
marine algae.
40
Table 4. DHA content of an average portion of

oily fish (150g) commonly consumed in Ireland
Omega-3-containing fish
Serving
size
(g)
DHA
content
(mg)
Average portion* of tuna

steak
120
2,749
Average portion* of salmon
120
2,485
Average portion* of mackerel
120
1,507
Average portion* herring

kippered
120
902
Average portion* of Rainbow

trout
120
641
1 small tin of tuna
70
47.2
Limit tuna intake to one fresh tuna steak (150 g) or two 240 g cans of tinned
tuna per week during pregnancy due to mercury content
disposable cup**
Vitamin A during pregnancy

Why is vitamin A important during
pregnancy?
Vitamin A, also called retinol, is a fatsoluble vitamin which helps to strengthen
immunity against infections. Vitamin A is
involved in the maintenance of healthy
skin and mucus linings, e.g. in the nose,
and improves vision in dim light. It is also
important for the development of the
foetus.
During pregnancy, the recommended
daily intake of vitamin A is 700g. A
healthy and balanced diet provides
sufficient vitamin A for pregnant women.
How can a pregnant woman get enough vitamin A from

her diet?
A woman eating a varied diet will easily achieve this. Good
sources include whole milk (vitamin A is a fat soluble vitamin),
cheese, eggs and some fortified milks and cereals (Table 5).
See below: Portion Size Reference Guide - Portion pack***
How much fish can be eaten during pregnancy?

Fish is a very important part of a healthy balanced diet and
pregnant women should be encouraged to include fish as part
of their weekly diet. However, certain types of fish can contain
contaminants, e.g. mercury, which may be harmful to the brain
of the developing foetus.
WARNING!
Larger fish contain more contaminants than other fish.
Therefore, pregnant women should avoid eating
marlin, shark, ray and swordfish, and should limit their
consumption of tuna to one serving of fresh tuna (150g)
per week, or two 240g cans of tinned tuna per week.
Table 5. The Vitamin A Content of Commonly

Eaten Foods in Ireland
Type of food
Serving
size
(g)
Vitamin A
content
(g)
1 matchbox size piece of

cheddar cheese
30
109
1 single portion pack*** of

butter
10
96
1 boiled egg
50
90
1 pot of full-fat plain yoghurt
125
45
See below: Portion Size Reference Guide-Portion pack***
What about long chain polyunsaturated omega-3 fatty

acid supplementation during pregnancy?
PORTION SIZE REFERENCE GUIDE
Pregnant women should be encouraged to meet their intake

requirements for these fatty acids through their diet. However,
a supplement may be needed for women who do not like oily
fish, who are vegan, or who find it difficult to consume enough
omega-3 rich foods in their daily diet.
Women should be advised to take an omega-3 and omega-6
supplement or a pregnancy-specific supplement in order to
avoid excessive intakes of other vitamins, such as vitamin A.
Portion Pack***
Portions of butter or spread found in cafs can guide
the amount to use. For example, one pat of fat spread
is more than enough for one slice of bread try and
make it do for two. Reduced fat polyunsaturated and
monounsaturated spreads are best.
41
What about vitamin A supplementation during

pregnancy?
If a pregnant women wishes to take a multivitamin, they
should choose one designed especially for pregnancy. Certain
standard supplements and fish liver products such as cod
liver oil are high in vitamin A, and these should be avoided
during pregnancy.
Supplements designed especially for pregnancy tend to be
lower in vitamin A than other supplements on the market and
are safer for pregnant women. Supplements taken should
not contain more than 100% of the recommended dietary
allowance (RDA) for vitamin A in women.
WARNING!
Very high amounts of vitamin A (greater than 7,000g/
day, which is more than 10 times greater than the
requirement for pregnant women) may harm the
developing foetus. Some foods such as liver and liver
products naturally contain very high amounts of vitamin A
and pregnant women need to avoid these foods.
Allergy during Pregnancy

If a woman is not allergic to a particular food or ingredient,
there is no good evidence to suggest that avoiding certain
foods during pregnancy protects an infant from developing
food allergies later in life. However, if there is a strong history
of nut allergy in the family, it may be advisable to avoid
peanuts.
Care should be taken that the woman does not consume
a food to which she herself is allergic.
A note on carotene
Carotene is a dietary precursor of vitamin A. Dietary
sources of carotene include brightly coloured
vegetables like carrots, peas, broccoli, red peppers
and spinach. Unlike foods naturally very high in vitamin
A, such as liver and liver products, it is impossible to
get too much vitamin A by consuming these dietary
sources of carotene.
Therefore, pregnant women do not need to avoid

potentially allergenic foods during pregnancy, e.g. eggs,
fish, milk or milk products, unless they themselves are
allergic to these foods.
What is the bottom line in terms of good

nutrition for a healthy pregnancy?
1. Folic acid is important during the first 12 weeks of
pregnancy.
Pregnant women should take a folic acid supplement of
400g per day during the first 12 weeks of pregnancy. If
a mother has previously had an infant with a NTD, a
supplement containing 4,000g of folic acid is required
per day to help prevent recurrence.
2. Iron is important all throughout pregnancy.
Pregnant women should aim to eat iron-rich foods such
as those listed on page 7 twice daily.
3. Calcium is important all throughout pregnancy.
Three servings of milk or milk products daily should be
eaten, such as those listed on page 8.
4. Vitamin D is important all throughout pregnancy.
Pregnant women should be encouraged to eat vitamin D
rich foods, such as those listed on page 10. However, if a
woman does not include these sources in her diet and is
considering taking a supplement, a low dose supplement
containing 5g of vitamin D3 per day should be advised.
42
5. Consumption of oily sh should be encouraged throughout

pregnancy.
Consumption of oily fish, such as those listed on page
11, is recommended all throughout pregnancy to provide
essential long chain polyunsaturated omega-3 fatty acids
in the diet. However, large fish can contain substances
which may harm the developing foetus. As such, pregnant
women should avoid eating marlin, shark, ray and
swordfish, and should limit tuna to one serving of fresh
tuna (150g) per week, or two 240g servings of canned
tuna per week.
6. Excess vitamin A is harmful during pregnancy.
Pregnant women should avoid liver and liver products as
these are too high in vitamin A. Frequently eating these
products may lead to the woman taking too much vitamin
A in her diet which may be harmful to the developing
foetus. Pregnant women should be encouraged to eat
other sources of vitamin A such as those listed on
page 11.
7. Any multivitamin recommended should be specific to the
needs of pregnant women.
If a supplement is deemed necessary, pregnant women
should be advised to only take supplements which are
specifically designed for pregnancy.
8. Potentially allergenic foods should not be avoided unless
the mother herself has an allergy.
Pregnant women do not need to avoid potentially
allergenic foods during pregnancy, e.g. eggs, fish, milk
or milk products, unless they themselves are allergic to
these foods.
Further information
HSE 2006, Healthy Eating for Pregnancy

www.healthpromotion.ie
Healthy Pregnancy, Pack of 4 booklets on a range of topics

related to healthy pregnancy is available to order online at
www.healthpromotion.ie. This pack includes a pregnancy
calendar and three booklets: Give your baby a breather,
Healthy Eating for Pregnancy and Feeding your baby.
HSE supported multimedia information resource for

expectant and new mothers www.whatsupmum.ie
1.3 Lifestyle Factors which are

Important for a Healthy Pregnancy
A healthy weight is important during pregnancy
An underweight pregnant woman has an increased risk of
a pre-term delivery and of delivering an infant of low birthweight or very low birth-weight. An overweight or obese
pregnant woman has an increased risk of delivering an
infant with complications such as macrosomia (excessive
birth weight), neonatal infection, hypoglycaemia and
respiratory distress, in addition to a greater risk of obesity in
later childhood. An overweight or obese mother also has a
higher risk of gestational diabetes and hypertension during
pregnancy, and of miscarriage or caesarean section.
It is easier for a woman to maintain a healthy weight during
pregnancy if she is a healthy weight before pregnancy. Obesity
affects over a fifth of adult women in Ireland today. Therefore,
all healthcare professionals should play a role in encouraging
all women of childbearing age to attain and maintain a healthy
weight.
How much weight should a woman gain during

pregnancy?
Deliberate attempts to decrease body weight are not
recommended during pregnancy. Instead, women who are
overweight or obese before pregnancy should aim to gain
less weight than is normally expected during pregnancy and
women who are underweight before pregnancy should aim
to gain a little more weight than is normally expected during
pregnancy. Pregnancy weight gain goals are to be used as a
guide to the weight gain pattern observed during pregnancy
(Table 6). The healthcare professional leading the care of the
pregnant mother may be best placed to give specific advice
on weight gain during pregnancy.
Calculating Body Mass Index (BMI)

Divide weight (kilograms) by height (in metres)
squared:
BMI (kg/m) =
Weight (kg)
Height (metres) x Height (metres)
43
Table 6. Pregnancy Weight Gain Goals Based on Pre-Pregnancy Body Mass Index (BMI)
Total weight gain
Rate of weight gain* 2nd and 3rd

trimester
Pre-pregnancy BMI
Range
(kg)
Range
(lbs)
Underweight <18.5kg/m2
12.5 18.0
28-40
0.51 (0.44 0.58)
1.0 (1.0 - 1.3)
11.5 16.0
25-35
0.42 (0.35 0.50)
1.0 (0.8 - 1.0)
7.0 11.5
15-25
0.28 (0.23 0.33)
0.5 (0.4 - 0.6)
5.0 9.0
11-20
Normal weight 18.5-24.9kg/m2

Overweight 25.0-29.9kg/m
Obese 30kg/m2
Mean (range)
kg/week
Mean (range)
lbs/week
0.22 (0.17 0.27)
0.5 (0.4 - 0.6)
* Calculations assume a 0.5 2.0kg (1.1 4.4lbs) weight gain in the first trimester. Adapted from Weight Gain during Pregnancy, National Academy of Science, 2009
Women build up some fat stores during pregnancy to ensure they have sufficient energy stores for breastfeeding. This is
accounted for in the guidelines provided above (Table 6).
1.3.1
What to eat for healthy weight gain

during pregnancy
There is a modest increase in a womans energy

requirements, i.e. the amount of calories required daily
throughout pregnancy.
Table 7. The Number of Additional Calories*

needed by Pregnant Women during each
Trimester of Pregnancy
When choosing foods to meet the modest increase in energy

requirements, preference should be given to foods rich in
essential vitamins and minerals, such as fruits and vegetables,
milk and milk products, and oily fish. See Table 8 for suitable
foods which can be consumed (1-2 extra healthy snacks per
day) to achieve the increased intake in energy during the
second and third trimesters of pregnancy.
Table 8. The Number of Calories in Suitable

Snacks for Pregnancy
Suitable snack food
Serving size
(g)
Calories
(kcal)
Soda bread: 1 slice

(with honey)
43 (10)
100 (29)
2nd Trimester
350
1 cup** of bran cereal
30
134
3rd Trimester
500
2 slices of wholemeal
toast (cheddar cheese
and tomato)
70
160
(30 of cheese
and 50 of
tomato)
(208 cheese
and 0 tomato)
1 small can of baked beans
140
111
Scrambled eggs
(2 eggs, no milk)
120
192
1 pot low-fat plain yoghurt
125
71
1 cup** of fortified
low-fat milk
200
84
1 cup** of fortified
full-fat milk
200
120
1 small tin of tuna

(canned in brine)
70
80.5

(canned in brine, drained)
70
105
1 fruit, e.g. banana, apple,

or 2 mandarin oranges
100
95
Trimester of pregnancy
Additional calories to be
consumed daily
(kcal/d)
1st Trimester
* An average adult female requires about 2,000kcal/day
disposable cup**
44
Caffeine and pregnancy
Smoking and pregnancy
Caffeine can be absorbed freely across the placenta, but is

not broken down by either the placenta or foetus. Caffeine
consumption in excess of 200mg per day has been shown
to have negative effects on an infants birth weight, even in
non-smokers. Therefore, pregnant women should keep their
caffeine intake below 200mg caffeine per day. See Table 9
for the caffeine content of frequently consumed foods
and drinks.
Smoking is harmful to the developing foetus and is wellknown to adversely affect foetal growth. Pregnant women
who smoke have an increased risk of giving birth to infants
with a low birth weight and with an increased risk of asthma.
Pregnant women should be strongly advised not to smoke
during pregnancy due to the harm caused to the developing
foetus. Pregnant women should also be advised to avoid
exposure to second-hand smoke.
Table 9. Caffeine Content of Frequently

Consumed Drinks and Foods
Alcohol and pregnancy

No amount of alcohol is safe during pregnancy. Alcohol harms
the developing foetus and increases the risk of miscarriage
and pre-term delivery. Pregnant women should avoid all
alcoholic drinks.
Caffeine-containing Drinks
Serving
size
(ml)
Caffeine
content*
(mg)
1 cup of brewed coffee
200
40 180
Food safety and hygiene
1 cup of instant coffee
200
30 120
1 bottle of cola
500
50 107
1 shot of espresso
30
29 92
1 bottle of diet cola
500
39 64
Good food preparation and hygiene practices are important

at all stages of life in order to prevent potentially harmful
foodborne illnesses. However, during pregnancy, this is
particularly important, as certain bacteria in food (such as
Listeria and Salmonella), or parasites (such as Toxoplasma
gondii) can be extremely harmful to the developing foetus.
1 cup of tea
200
19 21
1 cup of decaffeinated coffee
200
4 12
1 can of stimulant energy drink
230
0.15 88.0
Caffeine-containing Foods
Serving
size
(g)
Caffeine
content*
(mg)
1 bar of dark chocolate
45
31 41
* The exact amount of caffeine varies according to cup size, brewing methods
and brands of tea or coffee.
Mum dont
forget that
smoke, alcohol
and too much
caffeine will
harm me...!
45
Listeria Monocytogenes
Toxoplasmosis
Listeria monocytogenes is a pathogenic bacterium

which causes listeriosis. This bacterium is ubiquitous in
the environment. The consumption of contaminated
food is the main route by which listeriosis is
transmitted (80-90% of cases).
Toxoplasmosis is caused by the parasite Toxoplasma

gondii. Humans can become infected by ingesting
Toxoplasma oocystes found in cat faeces or by eating
raw/undercooked meat containing visible cysts seen
on infected food.
Invasive listeriosis affects high-risk individuals

such as pregnant women and the developing foetus.
Listeriosis is characterised by diarrhoea, headache,
fever, muscle pain, meningitis and septicaemia, as well
as spontaneous abortion.
When primary infection with Toxoplasma gondii occurs

in pregnancy, the organisms may be transmitted to
the foetus and may lead to spontaneous abortion or
serious handicap in the newborn.
Listeria monocytogenes is particularly dangerous to

high-risk individuals because it can grow at fridge
temperatures. Fortunately, this bacterium is killed by
pasteurisation and by cooking food. Unpasteurised
milk and dairy products made from unpasteurised
milk may be contaminated. Certain chilled foods
which are consumed without further treatment, i.e.
cooking, also have a higher risk of contamination. Such
foods include soft cheese (even those made with
pasteurised milk), pt, smoked salmon, deli meats,
soft-serve ice-cream, luncheon meats and preprepared salads, e.g. coleslaw.
Practical food safety and hygiene advice for

pregnant women
1.
Eat only freshly cooked food and well-washed freshly

prepared fruit and vegetables. If eating out, it is safer
to order hot dishes
2. Avoid the following foods:

Unpasteurised milk and dairy products made with
unpasteurised milk. Foods include all soft cheese
and mould-ripened cheese (even those made with
pasteurised milk), e.g. Brie, Camembert, goats
cheese, and blue cheese, e.g. Danish Blue, Stilton,
Roquefort
Pt made from meat, vegetables or fish
Smoked salmon and gravid lax fish
3. When preparing food:

Wash hands before handling food
Wash fruits and vegetables very well before eating
Keep raw and cooked meats separate and wash

hands and chopping boards properly after handling
uncooked food
Use different knives, chopping boards and other

kitchen utensils when preparing raw and cooked
meats to avoid cross contamination
Cook all food thoroughly, especially meat, and

serve hot
Raw and undercooked meat, poorly cured and

fermented meat products, and poorly washed salads
and vegetables are possible sources of Toxoplasma
gondii. To prevent infection, good hygiene practices
are important, especially after handling raw meat or
unwashed vegetables. Meat should be well cooked and
served piping hot with no visible pink meat. Pregnant
women should wear gloves when gardening or
changing cat litter, and wash their hands afterwards.
The fridge temperature must be below 5C to store

all food
Follow storage instructions carefully

Dont eat foods past their use-by dates
4. Always wear gloves when gardening or changing cat litter,

and always wash hands very well after these activities
What is the bottom line in terms of lifestyle

factors which are important for a healthy
pregnancy?
1. Encourage women of childbearing age to attain and/or
maintain a healthy weight before becoming pregnant.
To reduce the risk of complications during pregnancy,
pregnant women should ideally be a healthy weight before
becoming pregnant. Specific advice related to the amount
of weight a woman should gain during pregnancy should
be provided.
2. The additional amount of energy needed during
pregnancy is modest.
In the second and third trimesters, 1-2 extra healthy
snacks per day are all that are needed to cover a pregnant
womans additional energy requirements. See page 14 for
a list of suitable snacks.
46
3. Caffeine should be limited to no more than 200mg per day.

Limit the number of caffeine-containing beverages
consumed during pregnancy. See page 15 for the caffeine
content of commonly consumed beverages and foods.
4. Smoking is harmful to the developing foetus.
Smoking during pregnancy should be strongly
discouraged. Pregnant women who smoke should
be advised on smoking cessation and adequately
supported should they choose to cease smoking.
Further information: Give your baby a breather is
available to order online at www.healthpromotion.ie.
5. Alcohol is harmful to the developing foetus.
No amount of alcohol is safe during pregnancy. Women
should be advised not to consume any alcohol during
pregnancy.
What should I do if my blood pressure is too high?
6. Food safety and hygiene is important to protect mother

and infant during pregnancy.
1. Be as active as possible. The health care professional

leading the care of the pregnancy should provide advice
on a suitable exercise regimen.
Pregnant women should be particularly careful to follow

general advice on food safety during pregnancy. Further
information on food safety during pregnancy is available
at www.safefood.eu.
To help alleviate high blood pressure, advise the following:
2. Reduce intake of salt. Avoid high-salt foods, e.g. salty and

cured meats, stock cubes, instant gravies, packet soups
and ready-meals, and avoid adding salt to cooking or at
the table.
3. Eat at least 5 servings of fruit and vegetables every day.
1.4 Questions Commonly Asked

by Pregnant Women
What should I do if I am pregnant and have not started
taking folic acid?
If a woman is less than 12 weeks pregnant, she should
immediately start taking 400g of folic acid daily. She should
continue to do so until she is at least 12 weeks pregnant.
If a woman is more than 12 weeks pregnant, the time in
which neural tube defects could be prevented with folic acid
supplementation has passed. The pregnancy should be
routinely monitored with reassurance given as necessary
if the pregnancy is progressing normally.
How can I reduce morning sickness?

To help alleviate morning sickness, advise the following:
1. Have dry, starchy foods such as dry crackers, toast,
and cereal, regularly, to relieve nausea.
2. Have small frequent meals and snacks throughout
the day.
Have a healthy snack (page 14) as soon as is tolerated
after vomiting.
4. Eat 3 servings of milk or milk based products every day

(page 8).
What should I do if I become constipated?

To help prevent constipation or to alleviate symptoms, advise
the following:
1. Drink about 8-12 glasses (2-3 litres) of water every day
2. With increasing fluid consumption, increase the amount
of fibre in the diet:
a. Include wholegrain varieties of bread, cereal, pasta
and rice, as well as fresh fruit and raw or cooked
vegetables, peas and beans
b. Soak linseeds overnight and add 1-2 dessertspoons
to cereal, meals, etc
3. Eat at least 5 servings of fruit and vegetables each day.
Include at least 1 serving with meals and snack on fruit
between meals
Take gentle exercise every day. The healthcare
professional leading the care of the pregnancy should
offer advice on an appropriate exercise regimen during
pregnancy.
Despite nausea, it is important to encourage the pregnant

woman to keep taking a daily supplement of 400g of
folic acid.
47
What should I do if I am not gaining enough weight

during my pregnancy?
It is important to assess the womans diet ensuring it is
balanced and varied with all foods from the 5 main food
groups included every day.
Advise the following:
1. Do not fast or skip meals
2. Choose foods from the 5 main food groups in line with
healthy eating guidelines for adults
3.
Do not exercise excessively. Speak with the healthcare

professional leading the care of their pregnancy about
an appropriate exercise regimen
4. Arrange a consultation with a dietitian if gaining weight

remains a difficulty
What should I do if I am gaining too much weight during

my pregnancy?
What can I do to relieve heartburn?

To help alleviate heartburn, advise the following:
1. Have smaller and more frequent meals in place of fewer
larger meals to help avoid reflux of stomach contents
2.
Avoid eating foods which classically trigger heart burn,

e.g. fatty fried foods (slow down digestion), chocolate and
caffeine (both relax the lower oesophageal sphincter)
3. Avoid eating late at night if heartburn occurs at bedtime

4. Elevate the upper body in bed (using pillows as
necessary). This can help prevent regurgitation of stomach
contents as can happen when lying completely flat
Are herbal teas safe during pregnancy?

Most common herbal teas, e.g. camomile, peppermint, and
ginger, are safe in moderation during pregnancy. Some herbal
teas may contain caffeine. The caffeine content should be
checked to ensure the woman keeps her caffeine intake
below 200mg per day.
It is important that the diet is balanced and the woman is

taking what is needed from the main food groups without too
many foods which are high in fat, salt, sugar, e.g. confectionary,
cakes, biscuits, crisps, and chocolate.
Women should be advised to avoid medicinal herbs

and supplements, e.g. Kava, Ginseng, Valerian Root, and
Echinacea, as they are not tested for safety in pregnancy.
However, deliberate weight loss during pregnancy is not

recommended.
Im a vegan how can I ensure my baby gets the right

nutrients to develop properly?
Advise the following:
A vegan diet is restrictive. It may be difficult to get enough

protein, iron, calcium, and vitamin B12 from this diet nutrients
essential for the health of both the mother and developing
foetus.
1. Have one or two fruit or low-fat dairy based snacks per day
2. Exercise according to the advice from the healthcare
professional leading the care of the pregnancy
3. Avoid high-fat and high-sugar confectionery and snacks
5. Avoid fried foods
What foods should I avoid when I am pregnant?
It is possible to get too much vitamin A from natural foods.

Excessive intakes of greater than 7,000g per day of
vitamin A, well above the requirement of 700g for
pregnant women, may harm the developing foetus. As
such, food sources very high in vitamin A should be
avoided during pregnancy, i.e. liver and liver products.
Some foods carry a greater risk of serious foodborne

illnesses in high-risk groups such as pregnant women.
To help prevent foodborne illness, pregnant women
should follow the advice on pages 15 and 16.
Limit tuna intake to one fresh tuna steak (150g) or

two 240g cans of tuna per week to avoid excessive
mercury intake.
There is not enough evidence to say avoiding allergenic

foods during pregnancy can protect an infant from
developing allergies. However, if there is a strong history
of nut allergy in the family, it may be advisable to
avoid peanuts.
To ensure the mothers diet is meeting the necessary dietary

requirements, a consultation with a dietitian should be
arranged.
I am concerned about my gestational diabetes

and the size of my infant
Most women with gestational diabetes are able to control
their blood glucose levels and avoid harm to themselves or
their infant. Following diagnosis, dietary education should be
provided to the pregnant women with the aim of stabilising
blood glucose levels. The healthcare professional leading the
care of the pregnancy should measure blood glucose levels
regularly to assess the need for insulin and the size of the
growing foetus should be monitored.
This chapter is from Best Practice for Infant

Feeding in Ireland: From Pre-conception
Through the First Year of an Infants Life - A
practical guide for healthcare professionals based
on the Scientific Recommendations for a National
Infant Feeding Policy, 2nd Edition (FSAI, 2012).
The booklet is available to download from
www.fsai.ie or a hardcopy can be requested
from the FSAI advice line (1890 33 66 77).
48

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CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

CLINICAL PRACTICE GUIDELINE

Nutrition for Pregnancy

Institute of Obstetricians and Gynaecologists,

Date of publication: August 2013

Revision date: August 2016

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

Purpose and Scope ......................................................................... 5

Background and Introduction ........................................................... 5

Clinical Guidelines .......................................................................... 8

Weight Gain ................................................................................... 8

Nutrient Overview ......................................................................... 10

Folate/ Folic acid ........................................................................... 15

Foods to Avoid ............................................................................. 19

Toxicological substances ................................................................. 19

Food borne infections ..................................................................... 20

Hospital Equipment and Facilities..................................................... 20

Provision of information on best practice for infant feeding ................. 21

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

Implementation Strategy ................................................................ 29

Key Performance Indicators ............................................................ 30

Qualifying Statement ..................................................................... 30

Appendix 1 - Useful websites ..................................................................... 31

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

1. Purpose and Scope

2. Background and Introduction

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

Medline, EMBASE and Cochrane Database of Systematic Reviews were

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

Guidelines reviewed included:

FSAI 2011 Scientific Recommendations for a National Infant Feeding Policy,

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

Therefore normal weight

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

therefore it is essential to check maternal weight and height at an antenatal

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

Distribution of weight gain in pregnancy

Stores of fat, protein and other 3.2 kg

4.2 Nutrient Overview

Women should be advised to take a daily supplement of 400 micrograms

The Food Pyramid guidelines are summarised below:

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

this group; Where one serving is 1 bowl of cereal, 1 slice of bread or 1

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

CLINICAL PRACTICE GUIDELINE

NUTRITION FOR PREGNANCY

Conversely, excessive maternal weight during pregnancy is associated with large