Giving Baby the Healthiest Possible Start

To help you provide this essential advice, here is more specific information about the impact of lifestyle and diet in pregnancy and foetal immune system development. Practical suggestions on nutrition and lifestyle questions to ask mothers, that can be fitted into your existing classes and protocols, are also given.

Nutrition and the development of a healthy immune system
The immune system is a complex defence mechanism that protects against illnesses and infections. Immunity is obtained via the:

• innate immune system, that consists of physical and chemical barriers (such as the skin or gut lining) and cells like white blood cells that can engulf and digest bacteria and foreign particles¹
• acquired immune system, that is involved in the specific recognition of foreign bodies (antigens) to which an antibody is produced to attack and render the foreign body harmless¹

Furthermore, a healthy immune system is able to stimulate the growth and repair of mucosal linings¹, especially in the gut and so:

• reduces any vulnerability to micro-organisms
• targets pathogenic bacteria to prevent their growth and their adhesion to the gut wall
• kills infected cells
• destroys some viruses and encourages the growth of beneficial bacteria

These processes help the body to develop more resistance to infections.

The role of the mother in foetal immune system development
The nutrients required by the foetus for a healthy immune system are derived from the mother`s diet and transported across the placenta. In the early stages of foetal development, the building blocks of the innate immune system are formed². These building blocks require the nutrients obtained from proteins, fats, vitamins and minerals in foods, as well as carbohydrates to fulfil energy needs. Nutrients that are particularly important for the immune system are the fat-soluble vitamins^3,4 and the minerals iron⁵, zinc^6,7 and selenium⁸.

In the last trimester of pregnancy, Long Chain Polyunsaturated fatty acids (LCPs) (a particular type of omega-3 fats found in oily fish and linseed oil)⁹ and vitamin E³ are transferred from the mother to the foetus to further boost the immune system. Antibodies that are important in the acquired immune system of the foetus are also transferred at this time. These antibodies confer acquired immunity on the baby for the first three months of life.

It is therefore important for both the maternal and foetal immune systems that a balanced, healthy diet containing a wide variety of beneficial nutrients is consumed throughout pregnancy (see Table 1).

Practical advice
You as a midwife can help by generally assessing nutrition and lifestyle habits during your booking and subsequent appointments to ensure that a wide variety of healthy foods are eaten. The following information has been provided to assist you with this role in an easy-to-use and timesaving format:

• recommended daily intake table: a quick guide to recommended food groups, amounts and reasons they are important for immune system and foetal development

Table 1: Recommended 10 daily intake to support the immune system and foetal development * Prebiotics are non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth and activity of specific “friendly” bacteria (also called probiotics) in the intestinal tract. In other words, prebiotics are foods not for us, but for our “good” bacteria because they stimulate their growth in our digestive tracts. Foods rich in prebiotics include bananas, garlic, leeks, onions and tomatoes
** see checklist on foods to avoid in pregnancy

CHECKLIST: Five questions to help you assess mums` nutrition ... with TOP dietary hints and tips to help ...

1. Are you eating breakfast on a daily basis?
TOP TIPS for a healthy breakfast, to provide a wide range of beneficial nutrients including minerals like selenium and zinc that support optimum immunity function

- breakfast cereal with raisins and milk
- yoghurt with fresh fruit and sunflower seeds

2. How many times do you eat fruit and vegetables each day?
Fruit and veg are a great source of antioxidant vitamins important for immune system development

TOP TIPS for increasing fruit and veg intake to the required five times daily

- a small glass of fresh fruit juice/smoothie every day
- add vegetables to stews/casseroles/pasta sauces

3. Do you eat starchy foods such as potatoes, rice, pasta or bread at every meal?
TOP TIPS on wholegrain starchy foods that can provide the immune supporting minerals, iron and selenium

- wholemeal and seeded breads (seeds are especially good in providing vitamin E that is key for the developing immune system)
- potatoes cooked in their skins

4. Do you eat protein foods like meat, fish, eggs, beans or nuts twice a day?
TOP TIPS on protein intake

- oily fish such as salmon, mackerel and sardines provide omega-3 fats important in the development of the brain and eyesight

5. What type of milk do you consume?
Skimmed or semi-skimmed milk has as much calcium as full fat milk and is suitable during pregnancy. Soya milk, oat milk and rice milk should be calcium-enriched

TOP TIPS for using milk and milk products, useful sources of fat soluble vitamins as well as zinc

- have custard with fruit or pudding
- a cheese sauce is great on vegetables

Foods for mum to avoid in pregnancy
1. Foods extremely high in vitamin A such as
liver, fish liver oils and vitamin supplements that contain vitamin A (retinol)

2. Certain oily fish¹¹ due to their high mercury content
- shark, swordfish and marlin
- fresh tuna (should be limited to two tuna steaks/week or four medium sized cans)

3. Peanuts and their products
There is currently inconclusive evidence whether all pregnant and lactating women should avoid exposure to nuts, although a number of mothers choose to do so¹²

4. Foods that may contain salmonella
- soft or raw eggs (white and yolk need to be solid when eaten)
- shellfish
- home-made mayonnaise, souffles or egg custards
- soft whipped ice creams
- undercooked poultry

5. Foods that may contain listeria
- soft, ripened cheeses (eg. Brie) and blue veined cheeses
- all unpasteurised dairy products
- paté
- ready prepared salads (including coleslaw) and pre-washed salad leaves

6. Other
- undercooked meat products (like hamburgers)
- raw meats (e.g. salami, Parma ham)
- take-away meals which may have been heated inadequately or `leftovers`

CHECKLIST: Important lifestyle issues beyond food
1. Are folic acid supplements being taken?
400 μg should be taken daily up to week 12 (see useful sources of information).

2. How many cups of tea/coffee/cans of cola are drunk daily?
A maximum of two mugs of coffee, two mugs of tea or five cans of cola daily is advised, to limit intake of caffeine to 200 mg/day¹³

3. Is alcohol being drunk? If so, how much and how often?
Government advice states that it’s best to stop drinking alcohol altogether in pregnancy. But if drinks are consumed, no more than 1 or 2 units of alcohol once or twice a week is advised¹⁴

4. Is the mother smoking?
An NHS helpline number to provide support in stopping smoking is 0800 022 4 332

Next steps: Nutrition beyond birth

Breastfeeding is Important
The best way to give a baby a great start in life is to encourage breastfeeding. Breastmilk is rich in antibodies that ensure a strong immune system and reduce the risk of infections and allergies^{15, 16, 17}. Breastmilk contains over 15 different immune factors, including prebiotic oligosaccharides. All of which have a positive effect on the baby`s immune system.

As yet, it has not been possible to add these exact immune factors into infant formulae. The benefits to a baby`s immune system must therefore be one of the major reasons to encourage breastfeeding.

Discussion regarding any perceived barriers to breastfeeding, as well as the actual process and benefits, is extremely important. A positive approach by healthcare professionals in such discussions - during appointments and classes in midwifery-led care - should be prioritised.

Bottle Feeding
For mums who are unable to or choose not to breastfeed, an infant formulae that contains prebiotic oligosaccharides to help support a baby`s natural immune system^{18, 19} should be considered. Therefore parents who bottle feed are best advised to select brands such as Cow & Gate and Aptamil which contain prebiotic oligosaccharides.

Useful sources of information

For Midwives
Royal College of Midwives
Website: www.rcm.org.uk

Food Standards Agency Eat Well
Website: www.eatwell.gov.uk/agesandstages/pregnancy/whenyrpregnant

Healthy Start Vitamins for Women (provides the only product to give the correct amount of folic acid together with Vitamin D but does not contain additional vitamin A²⁰ (as this poses teratrogenic risk) Available free to Healthy Start beneficiaries and at low cost from Primary Care Trust and Health Board outlets/pharmacies
Website: www.healthystart.nhs.uk

In Practice HCP Helpline 08457 623 624

For mums
Cow & Gate website for mums www.cowandgate.co.uk

National Childbirth Trust
Website: www.nct.org.uk

Emma`s Diary (consumer advice centre endorsed by The Royal College of General Practitioners)
www.emmasdiary.co.uk

Smoking Cessation
www.gosmokefree.co.uk/whygosmokefree/smokingpregnancy/

Consumer friendly BBC website relating to all aspects of pregnancy
www.bbc.co.uk/parenting/having_a_baby/pregnancy_index.shtml

References

1. National Cancer Institute (2003): Understanding the Immune System: How it Works. Available from http://www.niaid.nih.gov/Publications/immune/the_immune_system.pdf
2. Calder PC, Krauss-Etschmann S, de Jong EC et al (2006): Early nutrition and immunity - progress and perspectives. Br J Nutr 96, 774-90.
3. Devereux G, Barker RN, Seaton A (2002): Antenatal determinants of neonatal immune responses to allergens. Clin Exp Allergy 32, 43-50.
4. Perez - Lopez FR (2007): Vitamin D: the secosteroid hormone and human reproduction. Gynecol Endocrinol 23, 13-24.
5. Failla ML (2003): Trace elements and host defense: Recent advances and continuing challenges. J Nutr 133, 1443S-1447S.
6. Wellinghausen N (2001) Immunobiology of gestational zinc deficiency. Br J Nutr 85 Suppl 2, S81-6.
7. Shah D, Sachdev HP (2006): Zinc deficiency in pregnancy and fetal outcome. Nutr Rev 64, 15-30.
8. Kodama H (1996): Essential trace elements and immunity. Nippon Rinsho 54, [Abstract only. Article in Japanese].
9. Dunstan JA, Roper J, Mitoulas PE et al (2004): The effect of supplementation with fish oil during pregnancy on breast milk immunoglobulin A, soluble CD14, cytokine levels and fatty acid composition. Clin Exp Allergy 34, 1237-42.
10. British Dietetic Association (2001): Manual of Dietetic Practice, 3rd Edition. Ed. B Thomas, Blackwell Science, Oxford.
11. Food Standards Agency: www.eatwell.gov.uk/healthydiet/nutritionessentials/fishandshellfish Accessed January 2007.
12. COT (1998): Consumer Products and the Environment - Peanut Allergy. DoH Crown Copyright.
13. Food Standards Agency: http://www.food.gov.uk/news/pressreleases/2008/nov/caffeineadvice Accessed September 2009.
14. Food Standards Agency http://www.eatwell.gov.uk/agesandstages/pregnancy/whenyrpregnant/ Accessed 29 May 2007.
15. Hansen LA, Korotkova M (2002): The role of breastfeeding in prevention of neonatal infection. Semin Neonatol 7, 275-281.
16. Quigley MA, Cumberland P et al (2006): How protective is breast-feeding against diarrhoeal disease in infants in 1990s England? A case-control study. Arch Dis Child 91, 245.
17. Muraro A, Dreborg S et al (2004): Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol 15, 291-307.
18. Knol J et al (2005): Colon microflora in infants fed formula with galacto- and fructo- oligosaccharides: more like breastfed infants. J Pediatr Gastroenterol Nutr 40, 36-42.
19. Fanaro S, Boehm G et al (2005): Galacto-oligosaccharides and long chain fructo-oligosaccharides as prebiotics in infant formulas: a review. Acta Paediatr Suppl. 94, 22-6.
20. More J (2007): Who needs vitamin supplements? Fam Health Care 17 (2), 57-60.