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Food Safety for Pregnancy

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Natalie Langdon-Wilkins

on 4 April 2014

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Transcript of Food Safety for Pregnancy

T. gondii
is Transmitted by eating undercooked or raw meat, drinking unpasteurized milk, cleaning cat litter boxes, gardening or playing in sand boxes with cat feces.
On rare occasions people can become infected by drinking contaminated water or by receiving an infected blood transfusion
Infection in the unborn child early in pregnancy can result in miscarriage, poor growth, early delivery or stillbirth.
Newborns infected with toxoplasmosis can experience eye problems, hydrocephalus (water on the brain), convulsions or mental disabilities.
Early detection is important! Several treatments can prevent vertical transmission to fetus.
Pregnant women should avoid changing cat litter; their feces can be infectious for up to a year!
("Invasion of the Brain Snatchers: Backgrounder: Toxoplasmosis - The Nature of Things", 2013)
Phytoestrogens are naturally occurring compounds found in various foods. Soy is highly concentrated in a type of phytoestrogens called isoflavones. (Jefferson
et al.,
Phytoestrogens have been celebrated for their many health benefits including lowered risk of osteoporosis, heart disease, breast cancer, and menopausal symptoms. (Patisaul & Jefferson, 2010)
Phytoestrogens interfere with our endocrine system to achieve many of these health benefits but this can also cause problems with fertility, pregnancy and development.
Phytoestrogens mimic estrogen in our bodies by binding to estrogen receptor sites.
"Soy ingestion increases amniotic fluid phytoestrogen concentrations in female and male fetuses" (Jarrell, Foster, & Kinniburgh, 2012)
Isoflavones have been shown to cause disruption of lactation, the timing of puberty, the ability to produce viable offspring, premature reproductive aging and compromised fertility. (Jarrell, Foster, & Kinniburgh, 2012)
Soy Protein Supplements
Artificial sweeteners can be used instead of sugar to sweeten foods and drinks.
You can add them to drinks such as coffee or iced tea, and they are found in many foods sold in grocery stores.
Many people use sugar substitutes as a way to limit how much sugar they eat.

According to HealthLinkBC and Vancouver Coastal Health the following sweeteners have been approved during pregnancy in low-moderate levels; aspartame, acesulfame potassium, neotame, sucralose, and thaumatine.
These sources also recommend taking caution with Stevia as it is not yet approved by the government but is deemed to be “safe” (www.hc-sc.gc.ca).

HealthLinkBC recommends staying away from saccharin and cyclamate as these compounds have unknown consequences in pregnancy.

- Hormonal changes in pregnancy = decrease in a woman's immune function.

- This increases the susceptibility of pregnant women to certain types of Foodborne pathogens

Listeria monocytogenes.

- With a pregnant woman, Listeria can be transmitted to your unborn baby; in 20% of pregnancies complicated by Listeriosis end in spontaneous abortion or stillbirth & two-thirds of surviving infants develop clinical neonatal Listeriosis.

- incidence of Listeria among pregnant women remains about
20 times
greater than compared with the general population.

(Tam, Erebara & Einarson, 2010)
In its UNRIPE form, papaya has a high concentration of latex.
The latex is predominantly composed of papain and chymopapain.
Possible complications of consumption of these compounds include:
Physiological development abnormalities
Induction of abortion
Unripe Papaya
According to Healthlink BC and Vancouver Coastal Health it is safe to flavour your food with herbs during pregnancy.
The following herbs are considered safe in moderate amounts: ginger, bitter orange /orange peel, Echinacea, peppermint, red raspberry leaf, rose hip, and rosemary.
Women are advised to check with their HCP about any herbs they may be taking in capsule, tablet or extract form.
For more information on the safety of herbs in pregnancy visit HealthLinkBC http://www.healthlinkbc.ca

Most commonly ingested pharmacologically active substance in the world (Weng et al, 2008)

Some examples of where caffeine can be found is coffee, tea, cocoa, chocolate, soda and medications.

Caffeine crosses the placenta, and caffeine clearance during pregnancy is slower than in a nonpregnant state

Caffeine has been implicated as a cause of spontaneous abortion, intrauterine growth restriction (IUGR), low birth weight (LBW) and preterm delivery (Weng et al, 2008).

Currently Health Link BC, Vancouver Coastal Health Prenatal Nursing Care Pathway, and older studies recommend having no more than 300mg of caffeine per day (about two 250ml cups of coffee or 6 8oz cups of black tea).

However, this is contradictory to the latest research. Current research suggests pregnant women will differ in the way they metabolize caffeine based on their genetics. The study found 300mg/day of caffeine for some women was implicated with a higher risk of preterm birth and miscarriage. For this reason, Patel and Rizzolo recommended limiting caffeine consumption to no more than 200mg/day (Patel, Rizzolo, 2012).

Food Safety And Pregnancy
Current Policies & Practices
Our Policy Recommendations
Implications for Nursing Care
"Research has shown that health care providers might not provide sufficient information about risks associated with food safety to pregnant women and that messages should be improved and targeted. There is ongoing work in Canada needed to address this." (Taylor & Galanis, 2010)
Papain acts like oxytocin and prostaglandins to cause uterine contractions which can induce early labour.
The Latex can also cause edema and hemorrhagic placenta which can complicate pregnancy also leading to premature delivery.
College of Family Physicians of Canada (April 2010), stated that
"thorough heating or cooking food is the best way to inactivate food-borne pathogens, improved standards and surveillance have reduced the prevalence of contaminated foods at grocery stores. It is
no longer
necessary for pregnant women to avoid foods like deli meats and soft cheeses; soft-cooked eggs; or sushi and sashimi"
(Tam, Erebana & Einarson, 2010).

There are natural sources of mercury found in the environment, but human activity (ie. mining, burning of waste and hydroelectric dams) has
increased the amount of mercury

found in soil & water.
Fish absorb this mercury, which your

body then absorbs when you eat the fish.
The fish highest in mercury are usually larger fish that eat smaller fish.
Cleaning, preparing or cooking fish will not remove or reduce any amount of mercury.
Pregnant and breastfeeding women are at

greatest risk
of the dangers associated with

eating fish with higher levels of mercury (harm an unborn baby or child's developing nervous system including a growing brain).
(HealthLinkBC, 2013)
Fish with
levels of mercury include:
- fresh or frozen tuna;
- shark
- marlin
- swordfish
- escolar
- orange roughy

(HealthLinkBC, 2013)

For pregnant and breastfeeding women (HealthLinkBC, 2013):

Serving Limit of Fresh or frozen tuna, shark, marlin, swordfish, escolar, and orange roughy:
150 grams
(5 ounces) per month (2 CFG servings a month)

Serving Limit of Canned albacore tuna:
300 grams
(10 ounces) per week (4 CFG servings a week)
“...whether seafood is raw or cooked, pregnant women should choose low mercury seafood over higher mercury varieties" (Tam, Erebara & Einarson, 2010)
Uncooked fish may contain toxoplasmosis and listeriosis.

pregnant women are recommended to avoid raw fish and shellfish such as sashimi and sushi (with raw fish), raw oysters, clams and mussels (HealthLinkBC, 2013).

pregnant women do NOT need to avoid raw fish if it is obtained from a reputable establishment, stored properly & consumed soon after purchase. Cooking & flashfreezing are effective methods for inactivation of parasites (VCH, 2013).
HealthLinkBC (2012) Guidelines to Prevent

· Avoid all
unpasteurized cheese and dairy products

· Do not eat
soft cheese
unless it is heated until it is steaming hot (74ºC); ie. brie,
camembert, and blue-veined cheese

· Avoid
smoked fish products
unless they have been canned, or used in cooked dishes. Imitation crab should only be eaten if it is in a cooked dish.

· Do not eat r
efrigerated pâtés and meat spreads
. Canned or shelf-stable pâté or meat spreads are safer options. Be careful with fresh produce.

· Do not eat
deli meats
such as bologna, roast beef or turkey breast and hotdogs, unless they are heated until to 74ºC.
What should we recommend?

· Wash hands well before and after handling/preparing food (esp. if touching raw meat), change dishcloths and towels daily
· Wash raw vegetables well
· Buying from a reputable supplier with approved food safety
· Do NOT eat undercooked meat;
poultry (74 Degrees), whole poultry (85 Degrees), ground poultry (74 Degrees)
- egg products (74 Degrees)
- meat dishes (68 Degrees)
- reheat food well to an internal temperature of 74 Degrees Celcius

(HealthLinkBC, 2012)

- Eggs are the most common cause.

- Pregnant women are not at increased risk of Salmonella Infection.

- Store eggs in the refrigerator & wash their hands/utensils/surfaces after contact with raw eggs.

- Avoid raw or lightly cooked egg or egg products; Eggs should be cooked until both the white and the yolk is firm; use pasteurized egg products whenever possible.

- Avoid raw sprouts of any kind (including alfalfa, clover, and radish). These can harbor dangerous bacteria such as Salmonella and E. coli.

(Tam, Erebara & Einarson, 2010)
By: Vickie Pearson, Annabelle Vaugeois & Natalie Langdon-Wilkins
(Adebiyi, Adaikan & Prasad, 2002)
("Why Shouldn't Pregnant Women Eat Papaya?", n.d.)
Avoid cleaning cat litter boxes if you are pregnant or trying to become pregnant
Wear gloves when cleaning the cat litter box, then wash your hands
Place a secure lid on your sandbox to prevent cats from using it as a litter box
Wear gloves when gardening, then wash your hands
BC Centre for Disease
Control (2013)
("Eat safely, eat well. Food safety during pregnancy", n.d.)
Pregnant women should be advised to do the following with respect to Listeria prevention;

1) limit the
amount & frequency
of consumption

limit the duration of storage
by choosing the freshest foods & consuming them in a timely manner

3) ensure that these foods are
kept at the correct temperature
(ie, less than 4°C) at ALL times (including during transport from the retail outlet to the home)
“We believe that some of their recommendations are not evidence-based (Einarson, Tam & Koren, September, 2010).”

What do you think? Which meal is safer?
Canadian Family Physician & College of Family Physicians of Canada

SETTING: British Columbia.

RESULTS: A total of 340 practitioners (41%) completed the questionnaire. While most (88%) physicians and midwives had heard of listeriosis, few (18%) were aware that infection was more common during pregnancy. One-third (33%) of practitioners counseled pregnant women about the risk factors for Listeriosis. The main reasons for not providing such counseling were lack of knowledge and the perception that Listeriosis was rare and not an important concern for pregnant women.

Rates of counseling were highest among midwives (84%) and lowest among physicians practicing outside the Lower Mainland of British Columbia (12%). Of those practitioners providing prenatal care, 47% counseled pregnant women about the risks of unpasteurized milk and 41% counseled women about the risks of consuming soft cheese; few counseled about the risks of consuming deli meat or raw hot dogs (25%), unwashed fruit and vegetables (12%), or refrigerated smoked seafood (6%).

CONCLUSION: Most prenatal care providers in British Columbia are unaware of the risk factors for listeriosis & the increased risk for pregnant women and do not counsel their pregnant patients about these risks.

(Kirkham C, Berkowitz J. 2010)

"identified gap between the information on food safety & listerosis that they needed during pregnancy and the resources that were available"

Taylor, M., Kelly, M, Brisdon, S, Berkowitz, J., Gustafson, K. & Galanis, E.(2012). Pregnant women's knowledge, practices, and needs related to food safety and listeriosis: a study in British Columbia. Can Fam Physician. 58(10):1106-12.

1x Coffee with pasteurized milk
1x Sunny-Side-up pasteurized egg
1x White Toast

1x Ham Sandwich on white bread
1x Coca Cola

1x Tofu Teriyaki with mixed vegetables
1x Chinese tea

1x Tea with pasteurized milk & stevia
1x Hard boiled pasteurized egg
1x WW Toast
1x Thai Papaya Salad
1x Coconut water
1x Spaghetti with Meatballs and fresh basil
1x non alcoholic beer.

"Nurses have both a professional and legal obligation to provide their clients with safe, competent and ethical care."
(CRNBC, 2012)
#2 Sushi with miso soup and japanese green tea.
- the added responsibility of charting pregnant patient's diet
- mandatory inservices/training required to educate and update nursing staff on this topic & recent research
- collaborating with other HCP's to ensure each individual has appropriate diet/notifying physician/RD if diet is inappropriate
- recognize normal/abnormal symptoms of pregnancy/associated illnesses
- prompt response to any indication of symptoms of diet-related illnesses
We found current research that, conflicts with many of the recommendations provided by the PHC
We would like to see some of the more recent knowledge contributed towards a formal policy that can be implemented while pregnant women are in hospital.
It is important to consider that many of the established recommendations have been based on animal or observational studies due to ethical issues surrounding pregnant women consuming potentially harmful substances.
A policy would provide a foundation for safe communication and establish consistent practice to implement an appropriate diet for pregnant women in hospital,
It would also reduce the potential for preventable errors or adverse events.
All patients admitted to hospital require an order for nutrition before foods or beverages can be delivered to the patient.
The Registered Dietitian (RD) has the authority to order an oral diet or to adjust an established diet order based upon accepted nutrition practices, ethical considerations and informed consent.
All nutrition orders written by the RD will be made in collaboration with the health care team, and the health care team and most responsible physician will be aware of all documented nutrition orders.
Patients will have a chart to document any foods that will be brought into the hospital and consumed by the patient, and these charts will be reviewed by nursing staff once a shift, with a copy made to store in the patients charts.
Nutrition orders required “after hours”, on weekends or statutory holidays must be ordered by a physician as RDs are not on-site and are not able to provide verbal orders per hospital policy.
The foundation of the policy should be based on the principles we have discussed throughout this presentation, with adjustments made as new evidence emerges.
Patient Education will include explaining to the woman and family the need to restrict certain foods and fluids during the initial admission to the hospital and again on discharge.
#1 Pork Tacos with fresh salsa
1x Virgin
lime Margarita

Adebiyi, A., Adaikan, P. G., & Prasad, R. N. (2002). Papaya (Carica papaya) consumption is unsafe in pregnancy: fact or fable? Scientific evaluation of a common belief in some parts of Asia using a rat model. British Journal of Nutrition, 88(2), 199-203. doi:10.1079/BJN2002598

Akingbemi, B. T., & Hessler, W. (2009, January 26). Soy protein renders womb unsuitable for pregnancy. — Environmental Health News. Retrieved from http://www.environmentalhealthnews.org/ehs/newscience/soy-protein-renders-womb-unsuitable

American College of Nurse-Midwives (2010). Eating Safely During Pregnancy. Journal of Midwifery & Women's Health, 55(6), 603–604

Avelino, M. M., Amaral, W. N., & Castro, A. M. (2014). Congenital toxoplasmosis and prenatal care state programs. BMC Infectious Diseases, 14(33), 1-47. Retrieved from http://www-ncbi-nlm-nih-gov.ezproxy.library.ubc.ca/pmc/articles/PMC3918215/#__ffn_sectitle

Cox, J (2009). What can I eat, doctor? Food safety in pregnancy. Contemporary ob/gyn.54(12), 12.

Eat safely, eat well. Food safety during pregnancy. (n.d.). Retrieved March 8, 14, from http://search.phsa.ca/cgi-bin/MsmGo.exe?grab_id=0&page_id=22792&query=reduce%20toxoplasmosis

Einarson, Tam & Koren (2010). Food-borne illnesses during pregnancy. Can Fam Physician, 56(9): 869–870.

Greenwood, D. C., Alwan, N., Boylan, S., Cade, J. E., Charvill, J., Chipps, K. C., ... & Wild, C. P. (2010). Caffeine intake during pregnancy, late miscarriage and stillbirth. European journal of epidemiology, 25(4), 275-280.

HealthLinkBC (2012, June). Food Safety During Pregnancy - HealthLinkBC. Retrieved March 25, 2014, from https://www.healthlinkbc.ca/healthyeating/food-safety-pregnancy.html

Invasion of the Brain Snatchers: Backgrounder: Toxoplasmosis - The Nature of Things. (2013, October 31). Retrieved from http://www.cbc.ca/natureofthings/features/backgrounder-toxoplasmosis

Jarrell, J., Foster, W. G., & Kinniburgh, D. W. (2012). Phytoestrogens in human pregnancy. Obstetrics and Gynecology International, 2012, 1-7. doi:10.1155/2012/850313

Jefferson, W. N., Padilla-Banks, E., Goulding, E. H., Lao, S. C., Newbold, R. R., & Williams, C. J. (2008). Neonatal Exposure to Genistein Disrupts Ability of Female Mouse Reproductive Tract to Support Preimplantation Embryo Development and Implantation. Biology of Reproduction, 80, 425-431. doi:10.1095/biolreprod.108.073171

Kirkham C, Berkowitz J. (2010). Listeriosis in pregnancy: survey of British Columbia practitioners' knowledge of risk factors, counseling practices, and learning needs. Canadian Family Physician. 56(4): 158-66.

Kuczkowski, K. M. (2009). Caffeine in pregnancy. Archives of gynecology and obstetrics, 280(5), 695-698.

Link Between High Soy Diet During Pregnancy and Nursing and Eventual Developmental Changes in Children. (2008, January 2). Retrieved from http://articles.mercola.com/sites/articles/archive/2008/01/02/soy-and-children.aspx

McAuliffe, K. (2012, February 6). How your cat is making you crazy. Retrieved from http://www.theatlantic.com/magazine/archive/2012/03/how-your-cat-is-making-you-crazy/308873/

Patel S., & Rizzello,, D. (2012). Q: Is caffeine safe during pregnancy?. Journal of the American Academy of Physician Assistants, 25(5), 69.

Patisaul, H. B., & Jefferson, W. (2010). The pros and cons of phytoestrogens. Frontiers in Neuroendocrinology, 31(4), 400-419. doi:10.1016/j.yfrne.2010.03.003

Prenatal Nursing Care Pathway for Public Health Nurses (PHN) (2013, January) Vancouver Coastal Health. 16-21.

Prenatal Nutrition - Health Canada. (2011, February 10). Retrieved March 9, 2014, from http://www.hc-sc.gc.ca/fn-an/nutrition/prenatal/index-eng.php

Tam, Erebara & Einarson (2010). Food-borne illnesses during pregnancy: Prevention and treatment. Can Fam Physician. 56(4), 341–343.

Taylor & Galanis, 2010. Food safety during pregnancy. Canadian family physician Médecin de famille canadien, 56(8), 750 – 751.

Taylor, M., Kelly, M, Brisdon, S, Berkowitz, J., Gustafson, K. & Galanis, E.(2012). Pregnant women's knowledge, practices, and needs related to food safety and listeriosis: a study in British Columbia. Can Fam Physician. 58(10), 1106-1112.

Weng X, Odouli R, Li DK (2008) Maternal caVeine consumption during pregnancy and the risk of miscarriage: a prospective cohort study. Am J Obstet Gynecol 198 (3):279.e1–8

Why Shouldn't Pregnant Women Eat Papaya?. Retrieved March 8, 2014, from http://hubpages.com/hub/Why-Shouldnt- Pregnant-Women-Eat-Papya
Our Policy Recommendations:
- All patients admitted to hospital require an order for nutrition before foods or beverages can be delivered to the patient (RD will oversee).

- Nurses will ensure all patients have the resources & knowledge to document their nutrition, and nursing staff will store in chart and reflect on diet; refer to a physician or RD if there are any concerns.

- Food safety to refer to (for pregnant patients) will be covered within this policy and include everything we have mentioned today - and will be updated with current research

- Patient education is critical!
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