Eating disorders are common, primarily among women, so special attention to such problems must be paid when treating pregnant women. The clinician will also want a detailed history of their current diet because
it is very common to have an essential amino acid deficiency, leaky gut, or malabsorption, along with vitamin and mineral deficiencies. The following are specific questions that need to be asked of the pregnant patient.

Many medications increase utilization of various vitamins and minerals that are necessary for daily function. Over time this often causes nutrient deficiencies. If the patient is still on the prescribed medication, it is often beneficial to supplement accordingly to prevent symptoms from occurring because of this depletion. Caution must be used before supplementation recommendations to assure the effectiveness of the medication will not be altered with the addition of the nutrient. Fortunately, information about drug and nutrient depletion is readily available at many websites, including www.WebMD.com. Birth control pills deplete vitamin C, zinc, magnesium, and vitamin B₆. The classification of statin drugs may cause CoQ₁₀ deficiencies, and proton pump inhibitors may decrease the body’s ability to absorb calcium.

If there is a history of alcoholism, do not assume that the drinking has stopped because of the pregnancy. This is a delicate topic. Oftentimes, it is easier to obtain the information once a relationship has been established and the patient feels more comfortable with you (see Chapter 27). Vitamins and minerals that are commonly depleted are vitamin B₃/biotin, folic acid, vitamin A/retinol, and zinc.

The following is a list of vitamins that are commonly depleted during smoking: vitamin B₅/pantothenic acid, vitamin B₆/pyridoxine, vitamin B₁₂/cobalamin, folic acid, antioxidants C and E, and beta carotene.

The clinician should consider detoxification issues that may include B vitamins, co-factors, and essential amino acids.

A previous history of abnormal Pap smears may suggest a history of low levels of beta-carotene, vitamin A, vitamin C, folic acid, or essential amino acids.

It has been this author’s clinical observation, based on historical symptomatology and laboratory testing, that women who have had multiple pregnancies may develop essential amino acid deficiencies. Generalized fatigue, weight gain, and insomnia are common complaints.

Avoidance of food groups could lead to imbalance/deficiencies. An example of this is in celiac disease. Elimination of wheat, barley, and rye from the diet, in addition to the malabsorption because of damaged intestinal villi, often leads to deficiencies of iron and B vitamins. Possible anemic conditions then need to be monitored.

If the patient is currently obese and they have tried to lose weight in the past, it is often a sign that their body is resistant to weight loss. There may be a nutritional deficiency that is a contributing factor. Areas that can block the body from fat burning and may need further evaluation include sleep disturbance, insulin
resistance, thyroid abnormality, female hormone imbalance, poor detoxification, inappropriate exercise (too much or too little), food allergies, stress, or medication use.

Many people rely on caffeine to give them an energy boost, feel awake, or as part of their social lifestyle. Stopping cold turkey is often difficult. Providing healthy alternatives that are safe to use during pregnancy can be of great assistance during this period. Switching to herbal teas or using carbonated water with a splash of fruit juice can ease the loss of a favorite beverage. Eating chocolate can also fall into this category. If the patient is dependent upon caffeine to wake up in the morning, this could be a flag for possible adrenal fatigue. Further evaluation is warranted.

There are many causes of miscarriages. Some common causes could be low progesterone, trauma, stress, an incompetent cervix, or premature rupture of membranes. There are times when the cause is not known. As a practitioner, it is important to discuss the causes. For example, if stress was a part of the issue, the practitioner can assist the patient with relaxation techniques, understanding the importance of ongoing chiropractic care, and appropriate supplementation to provide an opportunity for the body to keep and maintain the current pregnancy. For most women, after the first miscarriage, fear and anxiety over it happening with subsequent pregnancies is high.

Antibiotics are often over-prescribed and over-utilized. What the patient considers “not often” can be very different to the practitioner.

What are the conditions for which the antibiotics were prescribed (e.g., acne, sinus infection, bronchitis, etc.)? This will give the practitioner insight into how well the patient’s immune system is responding. Nutritional support may be needed during the pregnancy to prevent the need for antibiotics.

Antibiotic use may predispose the patient to developing dysbiosis and leaky gut. They may also decrease the manufacture of biotin in the gut.

A history of periodontal disease or dental caries often gives the practitioner insight into poor diet or bacterial overgrowth in the mouth. Amalgam fillings can often give insight to current health issues such as chronic Candida infections, fatigue, or obesity. Note that during pregnancy and breast feeding, testing for heavy metal toxicity using a chelating agent or treatment of toxicity is contraindicated. Once breast feeding has stopped, the clinician is then free to address this issue, preferably before the next pregnancy.

Vegetarianism is a healthy lifestyle choice and it is noteworthy that more than half of the world’s population maintains a vegetarian diet. However, any lifestyle can lead to nutrient deficiencies, which, over time, may need to be addressed during pregnancy or directly in the child.

Traditionally, four types of vegetarianism have been identified. A semi-vegetarian is one who will include fish, poultry, eggs, and dairy but not pork or beef in their diet. Lacto-ovovegetarians consume both dairy products and eggs. A lacto-vegetarian consumes dairy. A vegan or strict vegetarian consumes only plant products (5).

The following discusses the vitamins that are often low and/or deficient among vegetarians. Supplementation and/or adding in the appropriate foods are necessary for healthy gestation, breast milk production, and prevention of postpartum depression.

Producing ample breast milk takes additional energy that the mother needs to acquire from food. It is estimated that an additional 500 kcal are needed to meet this need. An average range of total calories in a given day is 2,500 to 3,000 kcal. Anything less than this may compromise the foundational nutrients needed to maintain lactation and the nutrient needs of the mother. This is an average, and the needs for each individual should be evaluated. Potential nutrient deficiencies that may have been present before conception, during gestation, and/or postpartum may need to be evaluated. Proper foods combined with appropriate supplementation can increase the quality of breast milk produced. The following discusses some of the highlights of what is considered to be foundational food to produce “optimal” milk (Table 18.1).

Fats Quality fats are needed for vitamin absorption and are the precursors to hormone production. During pregnancy, essential fatty acids are the expectant mothers’ primary fuel source while glucose is feeding the fetus. Cell membranes are derived from the essential fatty acids received in the diet. This determines the fluidity of each cell membrane and is critical for development of the infant’s brain and nervous system. The newborn is unable to make cholesterol and arachidonic acid, so it is important that a lactating mother supply this in breast milk. A common food that supplies eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) is fish. In recent years, concern has risen about mercury contamination with this food group. As of the writing of this chapter, wild caught salmon contains some of the highest levels of healthy fats while containing the lowest amount of mercury. Tuna should only be eaten once a month and king mackerel, swordfish, and tilefish should be eliminated. These fish have been found to contain higher levels of mercury. Though farm-raised salmon does not seem to contain mercury, concern has risen over polychlorinated biphenyls, which are thought to come from the fish feed (6). Consumption of farmraised salmon should be limited to once a month. If it
is necessary to supplement, the patient can choose a product that comes from anchovies, salmon, or sardines. An antioxidant should also be in the product to prevent rancidity. Rosemary oil and vitamin E are commonly used. The product should also have had any heavy metals and organochlorines removed during the processing and this should be stated on the label. For vegetarians, marine algae can be a source of DHA and is the food source for wild salmon. This can be a wonderful source of DHA without compromising the vegetarian’s stance on animal product consumption. An average dose of omega 3 oil ranges from 1 to 3 g per day. Dosages of 8 g or more may cause problems with clotting and is not recommended during the last few weeks of pregnancy (7).

Carbohydrates Foods that cannot be identified as a protein or fat are considered to be carbohydrates. Thirty to fifty percent of the diet should be from the carbohydrate category. Refined carbohydrates should be limited (sugar, refined grains, starch, sweeteners, and high fructose corn syrup [HFCS]). These carbohydrates are broken down quickly and easily into glucose, which can contribute to gestational diabetes. Unrefined carbohydrates (fruits and vegetables) are those that you typically find in nature. These contain a higher fiber content, which slows the absorption of glucose. They also provide more energy and add bulk to the stool. A balance of both is essential to the mother and infant.

Protein Protein is essential to life. It is needed to build skin, muscle, bones, and organs. It is also needed to make hormones, transport nutrients, act as enzymes, make antibodies, and maintain water balance. Animal proteins typically contain all of the essential amino acids needed; however, there is protein that can be derived from vegetable sources such as lentils, nuts, and soy. When relying on vegetable sources of protein, careful planning is necessary to avoid essential amino acid deficiencies’ because of the lower amino acid content found naturally in those foods. Ideal protein consumption can range from 60 to 150 g per day, making up approximately 30% of total calories. Calculation of a recommended amount of protein can be done by taking 0.75 to 1g of protein per pound of fat-free mass. Many body composition scales provide this information.

Fiber The recommended amount of fiber for adults is 20 to 30g per day. It is present in all plants that are eaten for food, such as fruits, vegetables, grains, and legumes. These foods will naturally contain a blend of both soluble and insoluble fiber, and both are needed in the diet. Some of the benefits of fiber are particularly important during pregnancy. Many women complain of constipation, excessive weight gain, and gestational diabetes. The addition of fiber assists and often prevents those common complaints and complications that can occur during this time. Fiber aids in detoxification, provides satiety, bulks up the stool, and helps to stabilize blood sugar. Patients who have a diet based on sugar and refined carbohydrates will be lacking in fiber. It is important to add fiber to the diet gradually to prevent abdominal symptoms.

When a lactating mother has problems with breast milk production quick intervention is needed. The following is a list of the more common causes of decreased milk production:

The production of breast milk requires additional calories above and beyond those that are needed during pregnancy. Food is always the foundation of the diet and should be the first thing that is assessed to ensure that enough daily calories from all food groups are being consumed. If additional assistance is needed, the use of herbal galactagogues may be used. Galactagogues stimulate the production or flow of breast milk in lactating women. Many formulary products will use a blend of multiple herbs. See Table 18.2 for commonly used herbs.

Breast milk is the perfect food for infants and has not been fully replicated or reproduced by formulas. The following discusses some of the more important components of breast milk and reasons why supplementation of formula may be needed.

Breast milk has three distinct phases of development: colostrum, transitional milk, and mature milk. Colostrum is produced postpartum, but small amounts can be expressed from the nipples as early as the 16th week of gestation. It is a yellowish (because of carotene), clear fluid that contains high levels of protein and immunoglobulins such as secretory IgA (SIgA). It is SIgA that provides the newborn with the initial protection against infection. This is accomplished in part by interfering with the translocation of organisms across the intestinal wall and mucous membranes. A decrease in respiratory disease, diarrhea, and sepsis is thought to be caused by this mechanism. Colostrum also acts as a gastrointestinal (GI) laxative, which causes meconium and mucus to be eliminated from the intestinal tract. The colostrum also contains enzymes that assist gut maturation and digestion of fats because of its lipase content.

Transitional milk, or fore milk, is often bluish-white, similar to the color of skim milk, and the hind milk is thicker and whiter. It takes 7 to 10 days postpartum to transition from colostrum to mature breast milk (8).

During pregnancy, the fetus is dependent on a maternal glucose supply. At birth, the newborn’s energy needs are increased and the infant rapidly uses up the small amount of glycogen stores in the liver. This is why it is common for newborns to have an initial low glucose level during the first few hours after birth. Allowing the newborn to breast feed as soon as possible after birth will provide an opportunity to stabilize the blood glucose levels and decrease the likelihood of the nursing staff to supplement with glucose during a hospital birth. Glucose supplementation often makes the newborn drowsy and less interested in latching on to the breast. Breast feeding at this critical time is needed for essential nutrients and bonding with mother (9).

Newborns have a limited ability for gluconeogenesis and ketogenesis to provide alternative energy sources. In addition, they have limited hepatic glycogen stores. Carbohydrates should make up a large part of the infant’s diet until 6 months of age. Lactose is the most abundant carbohydrate in maternal breast milk and is easily broken down to glucose and galactose. Bacteria then convert it into lactic and butyric acids, which play a critical role in GI health. At 3 months of age, the infant is able to produce amylase from the salivary glands and, at 6 months, from the pancreas. Because of this, it is not recommended to begin solid food introduction prior to 6 months of age. Introduction of solid foods before the infant has the ability to digest them properly may increase the likelihood of food allergies.

Essential amino acids make up the majority of the protein content within breast milk. It is estimated that the whey to casein ratio is 60:40 (10). In addition, breast milk also contains lactalbumin, which is easy for the infant to digest. Hydrochloric acid production in the stomach is low at birth but reaches adult levels by 6 months of age. Pepsin production will not reach adult levels until approximately the age of 2. The pH of breast milk is slightly acidic. The fat profile of breast milk is composed primarily of cholesterol and polyunsaturated fats. Fat in human milk is easier to digest than cow’s milk because of the presence of the enzyme lipase. During the first 6 months lipase is produced in the mouth and stomach. Because of this, the infant has the ability to hydrolyze triglycerides into free fatty acids and glycerol, and it is believed that they can digest up to 90% of the fat from their diet because of this. After 6 months, the infant will be able to produce lipase from the pancreas for complete fat digestion (11).

In addition to SIgA, there are many other immune benefits that are found in breast milk. B lymphocytes, macrophages, neutrophils, and T lymphocytes assist in the creation of antibodies against specific microbes, killing microbes in the gut, phagocytizing bacteria and viruses, killing infected cells, and strengthening the immune system (12). During gestation, the fetal gut is sterile. At the time of a vaginal birth, the newborn gets its first inoculation of flora. The quantity and species varies within the first 6 months of life and can contain up to 500 different species of microbes (13). Typically within the first few days, Escherichia coli and various strains of streptococcus are the first to inoculate. Additional bacteria are bifidobacteria, bacteroides, and clostridium. Lactoferrin is an enzyme in breast milk that is released during phagocytosis from neutrophils and macrophages that combines with iron in the blood. The binding of iron causes it to be unavailable to pathogens, which require iron for their reproduction. An example of such a pathogen is E. coli. The predominant flora in breast-fed babies tends to be from the bifidobacteria species, whereas in formula-fed infants the pattern of colonization changes based on the formula used (14).

Breast milk naturally contains vitamin C. If maternal levels of vitamin D are optimal, then the breast milk should contain adequate levels. Recent studies have shown that vitamin D deficiency is more common than originally thought, and it is highly recommended to test a women’s vitamin D level before pregnancy to detect suboptimal levels. 25-Hydroxy vitamin D is the proper form of vitamin D to test during routine laboratory assessment. If you suspect maternal levels may be low, supplementation of the mother and or appropriate sun exposure for the infant may be indicated. The calcium to phosphorus ratio in breast milk is 2:1, which is what is required for optimal bone mineralization in the newborn.

Vitamin K is produced in the gut from the gut flora and is not found in breast milk. It takes time for the flora to become established and vitamin production to begin. It is common for vitamin K to be administered immediately after birth to prevent bleeding problems such
as hemorrhage, petechia, or bruising in the newborn. During gestation the fetus begins to store iron, which should last through the first 6 months. Iron in general is poorly absorbed; however, the iron in breast milk has a higher rate of absorbability when compared with cow’s milk or formula.

Breast feeding problems almost always are because of an issue with the baby. An appointment should be made near feeding time so that the practitioner may observe the nursing positions and behavior of the infant. Careful assessment of the infant may reveal certain biomechanic abnormalities.

Baby’s Body Position The baby’s mouth should be in line with the nipple. Many mothers move their breast to the baby instead of adjusting the baby’s position. Moving the breast may decrease the flow of milk because the ducts literally are being bent. This often causes frustration for the infant. The natural direction of the nipple is slightly lateral. The use of pillows will often assist the nursing mother in finding an appropriate and comfortable position.

Temporomandibular Joint Dysfunction If the infant is unable to fully open their mouth to form a proper latch, feeding will be frustrating and possibly painful for both the infant and the mother. Many infants will clamp or bite down on the tip of the nipple, which will change the motion of the infant’s sucking. An ideal time to observe the opening and closing of the mouth is when the infant is crying. Chiropractic assessment and correction of the infant’s temporomandibular joint should provide immediate relief to the mother, less frustration to the infant, and an increase in the flow of milk. When observing the temporalis muscle during breast feeding, the clinician should see muscle contraction and relaxation as the infant feeds. The infant should also be able to fully open his or her mouth to not only take in the nipple but also a large majority of the areola. It may take several feedings for the baby to learn to fully open his or her mouth.

If a proper latch is not attained, the mother should start over until a proper latch occurs. Encouragement is critical; remind the mother that she is retraining her child to breast feed differently. The infant will learn quickly if the mother is able to stay calm and not get frustrated.

Decreased Motion of the Hard Palate The hard palate of the infant’s mouth plays a critical role in his or her ability to elicit a proper, strong sucking reflex. Signs that this may be a problem often are a weak suck. This can be assessed by placing the tip of the fifth digit into the infant’s mouth. A strong suck should feel like the finger nail will be pulled off. Palpating the hard palate should not elicit the gag reflex. If the doctor finds that the infant gags easily, it will be very difficult for them to attain a proper latch that includes the nipple and the areola. Chiropractic assessment to determine the side of decreased motion of the hard palate can be assessed by gentle palpation. A strong suck and diminished gag reflex are signs the proper correction has been made.

Cervical Rotation If the infant has decreased cervical rotation it will be difficult to attain a proper latch. A sign of this may be that the infant prefers to nurse on a specific side. After the chiropractic correction has been made, it is recommended that the mother feed on the side that will cause the infant to rotate their head toward the side of the original problem. By feeding from this side first, when the infant is hungry, it will provide the opportunity for the infant to learn that they are able to turn their head without the possible pain that they may have been experiencing.

When breast feeding is not an option, there are several alternatives from which the patient may choose. However, it is never possible to fully reproduce breast milk. Formulas are typically derived from either cow’s milk or soy. In general, either type will contain carbohydrates, fats, protein, vitamins, minerals, and water. Because of the processing and manufacturing, these formulas do not contain Igs, live cells (white blood cells), or enzymes. The taste does not fluctuate, nor does the content of formula change as the baby ages, unlike breast milk. The US Food and Drug Administration regulates the vitamin and mineral content so the patient will find similarities among formula products (15). It is within the content of the carbohydrates, proteins, and fats that subtle differences are found.

Cow’s Milk Formula Carbohydrates in formula are often in the form of lactose with additional maltodextrin, corn syrup solids, sucrose, modified corn starch, or modified tapioca starch.

The protein content is primarily a combination of whey and casein derived from nonfat cow’s milk. The variability is based on the manufacturer and can range from 100% whey to a 60:40 or 48:52 whey:casein ratio. Some companies offer the protein as “predigested” or hydrolyzed to assist in infant digestion. Keep in mind that casein is often harder for the infant to digest.

The fat content in cow’s milk-based formulas is from vegetable oils. Palm olein, soy, coconut, safflower, and sunflower are the more common sources. Each contains different percentages of mono- and polyunsaturated fatty acids.

Iron that is added to formulas is poorly absorbed when compared to absorption of iron from breast milk. It is estimated that absorption can be as little as 5% to 10% when compared to 50% to 75% in breast milk. Because of the poor absorbability, it is often necessary to add more iron into formula to optimize absorption levels; however, the form of iron used is harder for infants to digest and may contribute to harder stools.

Soy Formula Soy formulas originally were created to give alternatives to those infants who had an allergy to cow’s milk. This raises concern because soy is also a common allergy. Soy was also thought to possibly reduce colic; however, this has not been shown to be completely true in clinical practice. Concern must also be given to infants with early hypothyroidism because soy has been shown to possibly reduce absorption of exogenous thyroid given as a medication. The use of soy formula may cause an exacerbation of the thyroid symptoms.

Soy beans do not naturally contain lactose. Because lactose is the primary carbohydrate found in breast milk, soy formulas will often add sucrose or corn syrup. Lactose is needed to assist with calcium absorption and colonization of gut flora. For those infants who have been diagnosed as “lactose intolerant,” soy formula is often recommended. However, it is the author’s opinion that lactose intolerance is often over-diagnosed, with the true problem being an imbalance with digestion, leaky gut, or an actual food allergy or sensitivity.

The soy protein isolate contains all of the essential amino acids; however, the essential amino acid methionine is lower when compared to the levels contained in whey. Because of this, it is added to infant soy formulas. It is also common to see the addition of carnitine and taurine.

Palm, safflower, sunflower, coconut, soybean, and/or corn oil are the common sources of fats contained in soy formulas.

Phytates are a natural component of soy and bind calcium, iron, and zinc. Therefore, additional calcium is added to increase the likelihood of adequate absorption.

Soy-based formulas tend to contain 33% more sodium than what naturally is found in breast milk. This may contribute to elevated blood pressure problems in some infants.

Concern has been expressed when using soy formulas with pre-term and low birth weight babies because of the increased levels of aluminum found in soy.

Hypoallergenic Formula Hypoallergenic formulas were developed to reduce possible food allergy problems. Allergies are typically caused by the protein content of the formula. To reduce the allergenicity, the protein will either be “hydrolyzed” or “pre-digested.” This means the protein must be completely broken down. Unfortunately, this causes the taste to be very bitter.

The carbohydrates are destroyed during the manufacturing process, so any of the following will be added in: corn syrup, sucrose, corn starch, or tapioca. The additions of these sweet-tasting carbohydrates also serve to mask the bitter taste of the protein. These formula types also have a higher content of sodium. Medium chain triglycerides also are added; MCTs are not naturally found in nature and contain no essential fatty acids, but they seem to increase energy and boost growth.

Goat’s Milk In many countries goat’s milk is preferred to cow’s milk. It is currently regaining popularity in the United States. If an infant is sensitive to cow’s milk formula, some may do well with goat’s milk versus soy. When breast feeding in not an option, this is the first formula that the author recommends trying. In the majority of cases, it has been well received and tolerated.

Although goat’s milk contains lactose, it has less when compared with cow’s milk. A newborn up to 6 months of age needs an additional sugar to increase the carbohydrate levels, such as rice syrup. In addition, cane and corn syrup could also be used, but they contain higher levels of calories when compared with rice syrup. In clinical practice the author has observed less rice allergies versus corn or cane sugar allergies. It is also thought that, because of the lower lactose content, goat’s milk is a suitable formula for those infants who are suspected of having lactose intolerance.

Overall, the protein content of goat’s milk is very similar to human breast milk. One drawback to goat’s milk is that it contains trace amounts of alpha-S1 casein protein. For some, this may cause an allergic reaction; however, a benefit of goat’s milk is thought to be protein, which is easier for the infant to digest. So, if a baby did not do well with cow’s milk, they may do fine on goat’s milk. An additional potential for an allergy issue could also be the beta-lactoglobulin content. Clinically, it is impossible to tell which potential allergen (alpha-S1 casein protein or beta-lactoglobulin) the infant may be responding to adversely, both will cause the same symptoms.

The overall fat content in goat’s milk is higher when compared to cow’s milk. A benefit to using goat’s milk is there is no agglutinin. This means that the fat does not cluster in the gut, making it easier to digest. There is more linoleic and arachidonic acid content, in addition to higher short- and medium-chain fatty acids.

When comparing goat’s milk with cow’s milk, the following are in higher concentrations in goat’s milk: calcium, B₆, vitamin A, potassium, niacin, copper, and selenium. Folic acid and vitamin B₁₂ are lower in goat’s milk, so supplementation is recommended by using a multivitamin formula with additional iron up to 1 year of age. After age 1, supplementation is not needed if the child is eating solid food at that time.

Transitioning From Breast Milk or Formula to Goat’s Milk

Stay updated, free articles. Join our Telegram channel

Join