In the United States, there are different laws for medicines and for dietary supplements. The part of the FDA that controls dietary supplements is the same part that controls foods sold in the United States. Only dietary supplements containing new dietary ingredients that were not marketed before October 15, 1994, submit safety information for review by the FDA. However, unlike medicines, herbal remedies and "natural products" are not approved by the FDA for safety or for what they say they will do. Most have not even been evaluated for their potential to cause harm to you or the growing fetus, let alone shown to be safe for use in pregnancy. Before a company can sell a medicine, the company must complete many studies and send the results to the FDA. Many scientists and doctors at the FDA check the study results. The FDA allows the medicine to be sold only if the studies show that the medicine works and is safe to use.

Section 19.2 Aspirin and Pregnancy Excerpted from "Aspirin," by the Center for the Evaluation of Risks to Human Reproduction (CERHR, cerhr.niehs.nih.gov), part of the National Inst.i.tute of the Environmental Health Sciences, April 23, 2008.

Aspirin and Pregnancy The Food and Drug Administration (FDA) has issued the following warning about aspirin use during pregnancy: "It is especially important not to use aspirin during the last three months of pregnancy, unless specifically directed to do so by a physician because it may cause problems in the unborn child or complications during delivery."

Aspirin is listed on the California Environmental Protection Agency (CAL/EPA) Proposition 65 list of developmental toxicants. A 173 Pregnancy and Birth Sourcebook, Third Edition developmental toxicant is a substance that a group of expert scientists has determined can harm unborn children.

Aspirin and Breastfeeding Aspirin is transferred to breast milk and it is estimated that a nursing baby receives about 48% of the mother's dose. Continued exposure to small doses of aspirin may be harmful to babies because aspirin tends to build up in their bodies. In some countries, nursing women are advised against aspirin use because of the possible development of Reye syndrome in their babies. Reye syndrome is a rare condition that affects the brain and liver and is most often observed in children given aspirin during a viral illness (National Reye's Syndrome Foundation). Because sufficient information is not available to accurately determine the extent of aspirin acc.u.mulation in babies and the resulting health outcomes, the World Health Organization (WHO) Working Group on Human Lactation considers aspirin intake by nursing mothers as unsafe.

The American Academy of Pediatrics Committee on Drugs listed aspirin as a drug that has been "a.s.sociated with significant effects on some nursing infants and should be given to nursing mothers with caution." The report suggested that safer drugs such as acetami-nophen should be used for pain relief during pregnancy.

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Chapter 20.

Folic Acid Why can't I wait until I'm pregnant or planning to get pregnant to start taking folic acid?

Birth defects of the brain and spine (spina bifida and anencephaly) happen in the first few weeks of pregnancy; often before you find out you're pregnant. By the time you realize you're pregnant, it might be too late to prevent those birth defects. Also, half of all pregnancies in the United States are unplanned.

These are two reasons why it is important for all women who can get pregnant to be sure to get 400 mcg of folic acid every day, even if they aren't planning a pregnancy any time soon.

I'm planning to get pregnant this month. Is it too late to start taking folic acid?

The CDC recommends women to take 400 micrograms (mcg) of folic acid every day, starting at least three months before getting pregnant.

If you are trying to get pregnant this month, or planning to get pregnant soon, start taking 400 mcg of folic acid today.

From "Folic Acid," by the Centers for Disease Control and Prevention (CDC, www.cdc.gov), National Center on Birth Defects and Developmental Disabilities, January 30, 2008.

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Pregnancy and Birth Sourcebook, Third Edition I already have a child with spina bifida. Should I do any- thing different to prepare for my next pregnancy?

Women who had one pregnancy affected by a birth defect of the brain or spine might have another. Talk to your doctor about taking 4,000 micrograms (4.0 milligrams) of folic acid each day at least 1 month before getting pregnant and during the first few months of being pregnant. This is ten times the amount most people take. Your doctor will give you a prescription. You should not take more than one multivitamin each day. Taking more than one each day over time could be harmful to you and your baby.

Can't I get enough folic acid by eating a well-balanced healthy diet?

You might think that you can get all the folic acid and other vitamins you need from the food you eat each day. But it is hard to eat a diet that has all the nutrients you need every day. Even with careful planning, you might not get all the vitamins you need from your diet alone. That's why it's important to take a vitamin with folic acid every day.

I can't swallow large pills. How can I take a vitamin with folic acid?

These days, multivitamins with folic acid come in chewable chocolate or fruit flavors, liquids, and large oval or smaller round pills.

A single serving of many breakfast cereals also has the amount of folic acid that a woman needs each day. Check the label. Look for cereals that have 100% daily value (DV) of folic acid in a serving, which is 400 micrograms (mcg).

Vitamins cost too much. How can I get the vitamin with folic acid that I need?

Many stores offer a single folic acid supplement for just pennies a day. Another good choice is a store brand multivitamin, which includes more of the vitamins a woman needs each day. Unless your doctor suggests a special type, you do not have to choose among vitamins for women or active people. A basic multivitamin meets the needs of most women.

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Folic Acid How can I remember to take a vitamin with folic acid ev- ery day?

Make it easy to remember by taking your vitamin at the same time every day. Try taking your vitamin when you: * if you use a cell phone or PDA, program it to give you a daily reminder; * brush your teeth; * eat breakfast; * finish your shower; * brush your hair; * if you have children, take your vitamin when they take theirs.

Seeing the vitamin bottle on the bathroom or kitchen counter can help you remember it, too.

Today's woman is busy. You know that you should exercise, eat right, and get enough sleep. You might wonder how you can fit another thing into your day. But it only takes a few seconds to take a vitamin to get all the folic acid you need.

Are there other health benefits of taking folic acid?

Folic acid might help to prevent some other birth defects, such as cleft lip and palate and some heart defects. There might also be other health benefits of taking folic acid for both women and men. More research is needed to confirm these other health benefits. All adults should take 400 micrograms (mcg) of folic acid every day.

Can women get too much folic acid?

Unless their doctor advises them to take more, most women should limit the amount they take to 1,000 mcg a day.

What is folate and how is it different from folic acid?

Folate is a form of the B vitamin folic acid. Folate is found naturally in some foods, such as leafy, dark green vegetables, citrus fruits and juices, and beans.

The body does not use folate as easily as folic acid. We cannot be sure that eating folate would have the same benefits as getting 400 177.

Pregnancy and Birth Sourcebook, Third Edition micrograms of man-made (synthetic) folic acid. Women who can get pregnant should consume 400 micrograms of synthetic folic acid in addition to the natural food folate from a varied diet.

What is "synthetic" folic acid?

Synthetic folic acid is the simple, man-made form of the B vitamin folate. Folic acid is found in most multivitamins and has been added in U.S. foods labeled as "enriched" such as bread, pasta, rice, and breakfast cereals. The words, "folic acid" and "synthetic folic acid"

mean the same thing.

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Chapter 21.

Nutrition and Pregnancy Chapter Contents.Section 21.1-What to Eat: A Guide for Pregnant Women ..... 180 Section 21.2-Vegetarian Diets and Pregnancy ....................... 185 Section 21.3-Anemia and Pregnancy ....................................... 188 Section 21.4-What You Need to Know about Mercury in Fish and Sh.e.l.lfish ............................................... 190 Section 21.5-Caffeine Use during Pregnancy ......................... 191 179.

Pregnancy and Birth Sourcebook, Third Edition Section 21.1 What to Eat: A Guide for Pregnant Women Excerpted from "Staying Healthy and Safe," by the Office of Women's Health (womenshealth.gov), part of the U.S. Department of Health and Human Services, March 2009.

Eat this. Don't eat that. Do this. Don't do that. Pregnant women are bombarded with dos and don'ts. Here's help to keep it all straight.

Eating for Two Eating healthy foods is more important now than ever. You need more protein, iron, calcium, and folic acid than you did before pregnancy. You also need more calories. But eating for two doesn't mean eating twice as much. Rather, it means that the foods you eat are the main source of nutrients for your baby. Sensible, balanced meals combined with regular physical fitness is still the best recipe for good health during your pregnancy.

Calorie Needs Your calorie needs will depend on your weight gain goals. Most women need 300 calories a day more during at least the last 6 months of pregnancy than they do prepregnancy. Keep in mind that not all calories are equal. Your baby needs healthy foods that are packed with nutrients-not empty calories such as those found in soft drinks, candies, and desserts.

Although you want to be careful not to eat more than you need for a healthy pregnancy, make sure not to restrict your diet during pregnancy either. If you don't get the calories you need, your baby might not get the right amounts of protein, vitamins, and minerals. Low-calorie diets can break down a pregnant woman's stored fat. This can cause your body to make substances called ketones. Ketones can be found in the mother's blood and urine and are a sign of starvation.

Constant production of ketones can result in a child with mental deficiencies.

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Nutrition and Pregnancy Foods Good for Mom and Baby A pregnant woman needs more of many important vitamins, minerals, and nutrients than she did before pregnancy. Making healthy food choices every day will help you give your baby what he or she needs to develop. Here are some foods to choose often: * Grains: Grains: Fortified, cooked or ready-to-eat cereals; wheat germ Fortified, cooked or ready-to-eat cereals; wheat germ * Vegetables: Vegetables: Carrots, sweet potatoes, pumpkin, spinach, cooked greens, winter squash, tomatoes, red pepper Carrots, sweet potatoes, pumpkin, spinach, cooked greens, winter squash, tomatoes, red pepper * Fruits: Fruits: Cantaloupe, honeydew melon, mangoes, prunes or prune juice, bananas, apricots, oranges or orange juice, grapefruit, avocado Cantaloupe, honeydew melon, mangoes, prunes or prune juice, bananas, apricots, oranges or orange juice, grapefruit, avocado * Dairy: Dairy: Nonfat or low-fat yogurt; nonfat milk (skim milk); low-fat milk (1% milk) Nonfat or low-fat yogurt; nonfat milk (skim milk); low-fat milk (1% milk) * Meat and beans: Meat and beans: Cooked dried beans and peas; nuts and seeds; lean beef, lamb, and pork; shrimp, clams, oysters, and crab; cod, salmon, pollack, and catfish Cooked dried beans and peas; nuts and seeds; lean beef, lamb, and pork; shrimp, clams, oysters, and crab; cod, salmon, pollack, and catfish Talk to your doctor if you have special diet needs for these reasons: * Diabetes: Diabetes: Make sure you review your meal plan and insulin needs with your doctor. High blood glucose levels can be harmful to your baby. Make sure you review your meal plan and insulin needs with your doctor. High blood glucose levels can be harmful to your baby.

* Lactose intolerance: Lactose intolerance: Find out about low-lactose or reduced-lactose products and calcium supplements to ensure you are getting the calcium you need. Find out about low-lactose or reduced-lactose products and calcium supplements to ensure you are getting the calcium you need.

* Vegetarian: Vegetarian: Ensure that you are eating enough protein, iron, vitamin B12, and vitamin D. Ensure that you are eating enough protein, iron, vitamin B12, and vitamin D.

* Phenylketonuria (PKU): Phenylketonuria (PKU): Keep good control of phenylalanine levels in your diet. Keep good control of phenylalanine levels in your diet.

Food Safety Most foods are safe for pregnant women and their babies. But you will need to use caution or avoid eating certain foods. Follow these guidelines: * Clean, handle, cook, and chill food properly to prevent food-borne illness, including listeria and toxoplasmosis.

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Pregnancy and Birth Sourcebook, Third Edition * Wash hands with soap after touching soil or raw meat.

* Keep raw meats, poultry, and seafood from touching other foods or surfaces.

* Cook meat completely.

* Wash produce before eating.

* Wash cooking utensils with hot, soapy water.

Do Not Eat * Refrigerated smoked seafood like whitefish, salmon, and mackerel * Hot dogs or deli meats unless steaming hot * Refrigerated meat spreads * Unpasteurized milk or juices * Store-made salads, such as chicken, egg, or tuna salad * Unpasteurized soft cheeses, such as unpasteurized feta, Brie, queso blanco, queso fresco, and blue cheeses * Shark, swordfish, king mackerel, or tile fish (also called golden or white snapper)-these fish have high levels of mercury * More than 6 ounces per week of white (albacore) tuna * Herbs and plants used as medicines without your doctor's okay (The safety of herbal and plant therapies isn't always known.

Some herbs and plants might be harmful during pregnancy, such as bitter melon [karela], noni juice, and unripe papaya) * Raw sprouts of any kind (including alfalfa, clover, radish, and mung bean) Vitamins and Minerals In addition to making healthy food choices, ask your doctor about taking a prenatal vitamin and mineral supplement every day to be sure you are getting enough of the nutrients your baby needs. You also can check the label on the foods you buy to see how much of a certain nutrient the product contains. Women who are pregnant need more of these nutrients than women who are not pregnant.

Women who are pregnant also need to be sure to get enough vitamin D. The current recommendation for all adults under 50 (including 182 Nutrition and Pregnancy pregnant women) is 5 micrograms (mcg) of vitamin D each day. But many health experts don't think this is enough. Ask your doctor how much vitamin D you need each day. Because vitamin D is important to your unborn baby's development, your doctor might want to measure your vitamin D levels to be sure you are getting enough.

Keep in mind that taking too much of a supplement can be harmful. For example, too much of the nutrient vitamin A can cause birth defects. For this reason, only take vitamins and mineral supplements that your doctor recommends.

Table 21.1. Nutrients and Pregnancy Nutrients and Pregnancy Nutrient How Much Pregnant Women Need Each Day Folic acid*

400 micrograms (mcg) Iron 27 milligrams (mg) Calcium 1,000 milligrams (mg); 1,300 mg if 18 or younger Vitamin A 770 micrograms (mcg); 750 mcg if 18 or younger Vitamin B 122.6 micrograms (mcg) *Note: Women who are s.e.xually active also should take 400 micrograms of folic acid daily.

Don't Forget Fluids All of your body's systems need water. When you are pregnant, your body needs even more water to stay hydrated and support the life inside you. Water also helps prevent constipation, hemorrhoids, excessive swelling, and urinary tract or bladder infections. Not getting enough water can lead to premature or early labor.

Your body gets the water it needs through the fluids you drink and the foods you eat. How much fluid you need to drink each day depends on many factors, such as your activity level, the weather, and your size. Your body needs more fluids when it is hot and when you are physically active. It also needs more water if you have a fever or if you are vomiting or have diarrhea.

The Inst.i.tute of Medicine recommends that pregnant women drink about 10 cups of fluids daily. Water, juices, coffee, tea, and soft drinks all count toward your fluid needs. But keep in mind that some beverages are high in sugar and empty calories. A good way to tell if your fluid intake is okay is if your urine is pale yellow or colorless and you 183 Pregnancy and Birth Sourcebook, Third Edition rarely feel thirsty. Thirst is a sign that your body is on its way to dehydration. Don't wait until you feel thirsty to drink.

Alcohol There is no known safe amount of alcohol a woman can drink while pregnant. When you are pregnant and you drink beer, wine, hard liquor, or other alcoholic beverages, alcohol gets into your blood. The alcohol in your blood gets into your baby's body through the umbilical cord. Alcohol can slow down the baby's growth, affect the baby's brain, and cause birth defects.

Cravings Many women have strong desires for specific foods during pregnancy. The desire for "pickles and ice cream" and other cravings might be caused by changes in nutritional needs during pregnancy. The fetus needs nourishment. And a woman's body absorbs and processes nutrients differently while pregnant. These changes help ensure normal development of the baby and fill the demands of breastfeeding once the baby is born.

Some women crave nonfood items such as clay, ice, laundry starch, or cornstarch. A desire to eat nonfood items is called pica. Eating nonfood items can be harmful to your pregnancy. Talk to your doctor if you have these urges.

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Nutrition and Pregnancy Section 21.2 Vegetarian Diets and Pregnancy "Staying Healthy on a Vegetarian Diet During Pregnancy," Journal of Journal of Midwifery and Women's Health, Midwifery and Women's Health, January/February 2008. 2008 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission. January/February 2008. 2008 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission.

Why choose a vegetarian diet?

You may choose a vegetarian diet for many reasons. You may not want to harm animals. You may have political reasons for not eating meat. You may feel that not eating meat is healthier. Or you may avoid meat for religious reasons.

Is it possible to stay healthy without eating meat?

The American Dietetic a.s.sociation and many other health organizations say that vegetarian diets can be very healthy. Whatever your reason for choosing a vegetarian diet, you will need to learn a bit about nutrition in order to stay healthy-especially when you are pregnant.

What are the benefits of a vegetarian diet?

If you eat a well-balanced vegetarian diet, you will have a lower risk of: * obesity; * heart disease; * diabetes; * high blood pressure; * colon cancer.

If you already have some of these health concerns, eating a vegetarian diet may improve your health.

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Pregnancy and Birth Sourcebook, Third Edition Can I get enough protein without eating meat?

Yes, you can. Protein is made up of several amino acids. Animal products-like meat, fish, chicken, eggs, and milk-have all of the amino acids and are considered complete proteins. Plant foods-like grains, beans, and nuts-each have some of the amino acids, so they are usually incomplete proteins. By eating a wide range of plant foods, you can get all of the amino acids you need for complete protein. If you are not pregnant, you need about 46 grams of complete protein every day. That goes up to 71 grams per day when you are pregnant.

Are there other nutrients that I should pay attention to if I want to stay healthy on a vegetarian diet?

Other nutrients besides protein that you will want to make sure you get enough of are vitamin B12, vitamin D, calcium, iron, and essential fatty acids. The following text lists good food sources of these nutrients and some guidelines for how much to eat.

I've been a vegetarian for a while, but I just found out I am pregnant. What can I do to make sure my baby is as healthy as possible?

Most of us slip into habits and lose sight of exactly what we are eating every day. If you are newly pregnant, you might want to do something you probably did when you first became a vegetarian-keep a list of everything you eat every day for a while. Check your list against the recommendations to see if you are getting all the nutrients you need.

You can grow a healthy baby while eating a vegetarian diet.

What are diet guidelines for a healthy vegetarian diet dur- ing pregnancy?

In general, your daily diet should include: * one to two servings of dark green vegetables; * four to five servings of other vegetables and fruit; * three to four servings of bean and soy products; * six or more servings of whole-grain products; * one to two servings of nuts, seeds, and wheat germ.

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