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Official reprint from UpToDate www.uptodate.com ©2015 UpToDate

AuthorsJonathan Gillen-Goldstein, MDEdmund F Funai, MDHenry Roque, MD, MSJean M Ruvel, RD, CDE, CDN

Section EditorCharles J Lockwood, MD, MHCM

Deputy EditorVanessa A Barss, MD, FACOGDisclosures: Jonathan Gillen-Goldstein, MD Nothing to disclose. Edmund F Funai, MD Nothing to disclose. Henry

Roque, MD, MS Nothing to disclose. Jean M Ruvel, RD, CDE, CDN Nothing to disclose. Charles J Lockwood, MD,MHCM Consultant/Advisory Boards: Celula [Aneuploidy screening (Prenatal and cancer DNA screening tests indevelopment)]. Vanessa A Barss, MD, FACOG Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these areaddressed by vetting through a multi-level review process, and through requirements for references to beprovided to support the content. Appropriately referenced content is required of all authors and must conform toUpToDate standards of evidence.

Conflict of interest policy

Nutrition in pregnancy

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Aug 2015. | This topic last updated: Apr 14, 2015.

INTRODUCTION — A woman's nutritional status should be assessed preconceptionally with the goal of

optimizing maternal, fetal, and infant health. Pregnancy-related dietary changes should begin prior to

conception, with appropriate modifications across pregnancy and during lactation. (See "The preconception

office visit" and "Initial prenatal assessment and first trimester prenatal care".)

Most nutritional advice for pregnant women is based on the 1990 Institute of Medicine (IOM) Pregnancy Report

[1], the 2005 Dietary Guidelines for Americans by the United States Department of Health and Human Services

(HHS) and United States Department of Agriculture (USDA), and the following 2006 IOM publication: Dietary

Reference Intakes: The Essential Guide to Nutrient Requirements. The Recommended Dietary Allowances

(RDAs) are levels of nutrients recommended by an expert IOM panel based on extensive evaluation of available

scientific evidence and mathematically adjusted to meet the needs of 97 percent of the population.

Although it is clear that prenatal nutrition impacts short- and long-term health, many scientific questions remain

unanswered due to the many challenges to performing high quality scientific research in pregnancy. These

challenges include the often unknown critical windows of when nutrition may impact development, many

physiological changes that occur over the course of normal pregnancy, large individual differences in maternal

adaptation to pregnancy, ethical and practical issues of experimenting with human pregnancy, and the lack of a

good animal model that can be directly extrapolated to humans.

Nutritional concerns related to pregnancy will be discussed here. Dietary issues in nonpregnant adults are

reviewed elsewhere. (See "Healthy diet in adults" and "Vitamin supplementation in disease prevention" and

"Dietary and nutritional assessment in adults".)

ASSESSMENT OF NUTRITIONAL STATUS — Where available, nutritional assessment and counseling can

best be performed using a team approach, including the obstetrical provider, health professionals trained in

prenatal nutrition counseling and education, and a registered dietitian with perinatal nutritional expertise.

History — By asking appropriate questions, the medical history can help uncover habits, eating disorders, and

diseases (eg, Crohn's disease, diabetes) which pose nutrition-related health risks to the woman and her fetus.

The obstetrical history is also important. As an example, a past history of a fetus/child with a neural tube defect

would prompt advice to consume a higher dose of supplemental folic acid (4 mg rather than 0.4 mg) prior to

conception and in early pregnancy to reduce the risk of recurrence. (See "Folic acid supplementation in

pregnancy".)

A self-administered questionnaire completed prior to the interview is helpful for reviewing the woman's typical

diet, including a 24-hour dietary recall, and detecting obvious deficiencies (form 1) [1]. In general, women who

typically eat three meals daily consisting of several servings of vegetables, fruits, whole grains, low fat dairy

products, and a few sources of protein (eg, meat, fish, eggs, dried peas or beans) are likely to have adequate

nutrition. By comparison, women who skip several meals each week and/or have a high intake of soft drinks,

snack foods (eg, chips, candy, cookies), and fast foods can benefit from nutritional counseling by the physician

®®

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or midwife, nurse, or ideally a perinatal nutritionist (registered dietitian trained in perinatal health).

The following topics should also be addressed in the nutritional history:

Physical examination — The physical examination centers on measurements of height and weight to

calculate the body mass index (BMI) and assess whether the woman is at a healthy weight (table 1A-B). It is

useful to ask the woman what she weighed at her last menstrual period and use this weight for baseline

calculations. A prepregnancy BMI of 19.8 to 26.0 is normal. BMI tables incorporating pregnancy-related

changes in weight do not exist.

The remainder of the physical examination should screen for signs of nutritional deficiency or medical disease.

As an example, bulimia and other eating disorders may cause enlarged parotid glands and eroded tooth

enamel; anorexia can result in irregular menses, bradycardia, or dry skin. (See "Eating disorders: Overview of

epidemiology, clinical features, and diagnosis".)

Signs of gross vitamin deficiency are still seen in areas of the world with very poor diets. In resource-rich

countries, they occur only in special populations, including: patients with alcoholism, malabsorption, and inborn

errors of metabolism; those undergoing hemodialysis or receiving parenteral nutrition; and the elderly. (See

"Dietary and nutritional assessment in adults".)

PRECONCEPTIONAL RECOMMENDATIONS — (see "The preconception office visit", section on 'Diet and

supplements').

PREGNANCY RECOMMENDATIONS — The key components of a healthy lifestyle during pregnancy include

appropriate weight gain; appropriate physical activity; consumption of a variety of foods in appropriate amounts

to allow adequate, but not excessive, maternal weight gain; appropriate vitamin and mineral supplementation;

Substance use and abuse – Cigarettes, alcohol, and illicit drugs not only pose direct health risks, but

affect intake of an adequate and balanced diet. Stimulants may increase energy requirements.

●

Use of vitamin, mineral, or herbal supplements – Consumption of vitamin supplements containing

high doses of vitamin A (greater than 10,000 international units per day [1 IU = 0.3 mcg retinol

equivalents]) appears to be teratogenic and should be avoided [2,3]. High vitamin A intake from

consumption of liver potentially may also be harmful and some groups (eg, Finnish Food Safety Authority,

March of Dimes, National Health Service) have recommended that pregnant women limit or avoid liver

consumption for this reason [4-9].

Periconceptional folic acid supplementation is recommended since it reduces the risk of neural tube

defects. An increase in calcium and iron is important for bone and red blood cell development, while too

little or too much iodine can lead to fetal goiter. The lack of safety and efficacy studies of herbal remedies

preclude their use in any woman who is pregnant, contemplating pregnancy, or lactating (see 'Herbal

products and alternative therapies' below and 'Adverse effects from excess supplementation' below).

●

Food avoidances, special diets, skipping meals – These practices may lead to nutritional deficiencies

and inadequate weight gain during pregnancy.

●

Dieting history, weight fluctuations, eating disorders requiring medication or hospitalization – An

eating disorder may affect fertility, be aggravated by pregnancy, or complicate pregnancy. (See "Eating

disorders: Overview of epidemiology, clinical features, and diagnosis" and "Eating disorders: Overview of

treatment" and "Eating disorders in pregnancy".)

●

Food resources – Some women have financial constraints regarding the purchase, storage (eg,

refrigerator), or preparation (eg, stove) of adequate amounts of nutritional food. These women require

assistance from sources such as the Special Supplemental Food Program for Women, Infants, and

Children (WIC) or a social service agency.

●

History of bariatric surgery – Patients sometimes forget to disclose that they had bariatric surgery,

especially if it was in the distant past. Sequelae of bariatric surgery can affect pregnancy management.

(See "Fertility and pregnancy after bariatric surgery".)

●

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avoidance of alcohol, tobacco and other harmful substances; and safe food handling [10].

Avoidance of foodborne illnesses — Foodborne illnesses can cause maternal disease as well as congenital

disease, premature labor, miscarriage, and fetal death. To reduce the risk of foodborne illness, it is important

that pregnant women:

The US Food and Drug Administration (FDA) provides detailed advice on food safety for women who are

pregnant or planning pregnancy at: http://www.fda.gov/food/resourcesforyou/healtheducators/ucm081785.htm.

Foodborne illnesses can have adverse effects on the pregnancy and fetus, as well as the mother. The following

infections are of particular concern; these infections and strategies for avoiding them are described in detail

separately:

Prepregnancy weight and weight gain — Prepregnancy body weight and gestational weight gain have

independent, but cumulative, effects on infant birth weight and gestational duration. Underweight women with low

weight gain during pregnancy appear to be at higher risk of having a low birth weight infant, preterm birth, and

recurrent preterm birth [11-13]. Obese women are at increased risk of having a large for gestational age infant,

postterm birth, and a variety of other pregnancy complications. (See "The impact of obesity on female fertility

and pregnancy".)

The current Institute of Medicine (IOM) recommendations for singleton pregnancy are [14]:

The incidence of pregnancy complications is higher at the upper and lower extremes of weight gain. There is an

increase in births of small for gestational age (SGA) infants among women with a weight gain below the IOM's

BMI-based recommendations and women who exceed the weight gain recommendations approximately double

Practice good personal hygiene (frequent hand washing)●

Consume only meats, fish, and poultry (including eggs) that are fully cooked●

Avoid unpasteurized dairy products and fruit/vegetable juices●

Thoroughly rinse fresh fruits and vegetables under running water before eating●

Avoid eating raw sprouts (including alfalfa, clover, radish, and mung bean). Bacteria can get into sprout

seeds through cracks in the shell, these bacteria are nearly impossible to wash out.

●

Wash hands, food preparation surfaces, cutting boards, dishes, and utensils that come in contact with raw

meat, poultry, or fish with hot, soapy water. In addition, countertops can be sanitized by wiping with a

solution of one teaspoon liquid chlorine bleach per quart of water and leaving to dry over 10 minutes.

●

Toxoplasmosis – Toxoplasmosis is caused by ingestion of undercooked or cured meat or meat products,

soil-contaminated fruit or vegetables, and contaminated unfiltered water. (See "Toxoplasmosis and

pregnancy".)

●

Listeria monocytogenes – Listeria is a common low-level contaminant of both processed and unprocessed

foods of plant and animal origin, but hot cooked foods are not a vehicle of Listeria transmission. It is most

commonly associated with processed/delicatessen meats, hot dogs, soft cheeses, smoked seafood,

meat spreads, and paté. (See "Clinical manifestations and diagnosis of Listeria monocytogenes

infection".)

●

Brucellosis – Brucellosis is caused by ingestion of contaminated food such as raw milk, cheeses made

from unpasteurized (raw) milk, or raw meat. (See "Clinical manifestations, diagnosis, and treatment of

brucellosis".)

●

Body mass index (BMI) <18.5 kg/m2 (underweight) – weight gain 28 to 40 lbs (12.5 to 18.0 kg)●

BMI 18.5 to 24.9 kg/m2 (normal weight) – weight gain 25 to 35 lbs (11.5 to 16.0 kg)●

BMI 25.0 to 29.9 kg/m2 (overweight) – weight gain 15 to 25 lbs (7.0 to 11.5 kg)●

BMI ≥30.0 kg/m2 (obese) – weight gain 11 to 20 lbs (5 to 9.0 kg)●

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their risk of having a macrosomic infant. Large gestational weight gain may also increase the risk of childhood

obesity [11]. In addition, excessive weight gain during pregnancy and failure to lose weight postpartum appear to

predict higher BMI in the mother long after delivery, further supporting the IOM's recommendations for limited

gestational weight gain. These relationships are discussed in detail separately. (See "Weight gain and loss in

pregnancy".)

Interestingly, it has been observed that the birth weight of boys is about 100 g heavier than the birth weight of

girls, and this appears to be due to higher energy intake in pregnant women carrying males [15].

Dietary components — Specific dietary components do not appear to have a significant effect on birthweight

(see below) in resource-rich countries. Randomized trials have provided evidence that some dietary interventions

increase the length of gestation, but the evidence is not conclusive. There is no high quality evidence that any

dietary intervention reduces the risk of developing preeclampsia. These topics are discussed in more detail

separately. (See "Prevention of spontaneous preterm birth", section on 'Nutritional intervention' and

"Preeclampsia: Prevention".)

The effects of prenatal dietary components on child development and health are other active areas of

investigation. (See "Fish oil and marine omega-3 fatty acids", section on 'Early neurologic development' and

"Primary prevention of allergic disease: Maternal avoidance diets in pregnancy and lactation".)

In resource-limited countries, intake of both macronutrients and micronutrients during pregnancy appear to affect

pregnancy and early childhood outcomes [16,17], but these relationships are complex and controversial [18].

Macronutrients — Calories are the single most important nutritional factor in determining birthweight.

However, the relationship between energy intake, gestational weight gain, and birthweight is complex and poorly

understood [19]. If dietary supplements have any role in improving pregnancy outcome, benefits are likely

restricted to undernourished women.

Balanced energy/protein supplements – Compared with no energy supplementation, energy

supplementation during pregnancy (300 to 850 kcal/day with less than 25 percent of that energy coming

from protein) is associated with a small increase in maternal weight gain and birthweight, and a reduction

in the risk of SGA infants. A meta-analysis on use of balanced energy-protein nutritional supplements (11

trials, 5385 women) noted a small increase in birthweight compared to unsupplemented controls (mean

increase 41 grams, range 5 to 77 grams), but a significant reduction in the incidence of SGA infants and

stillbirth (SGA OR 0.79, 95% CI 0.69-0.90; stillbirth OR 0.62, 95% CI 0.40-0.98) [20]. Postnatal follow-up

was limited to a few trials and showed that these benefits were not sustained: compared to controls, there

was no difference in infant size or neurocognitive development at one year.

Undernourished women appear to experience the greatest benefit. A study in rural Gambian women found

that birthweight increased by approximately 200 grams in those receiving an energy-dense nutritional

supplement in the wet season (ie, when food shortages result in negative energy balance), but not during

the dry season (ie, harvest period with positive energy balance) [21]. The proportion of low birth weight

babies decreased from 24 to 8 percent.

Supplementation with protein alone or isocaloric protein supplementation (less than 25 percent of energy

in the supplement coming from protein) does not increase birthweight, and protein alone may decrease

birthweight [22,23].

●

Fat – Variations in the quantity and type of maternal fat intake have been associated with variations in

birth weight, gestational age and length, and neurodevelopment; however, available data are limited and

studies have reported mixed results, thus preventing clear conclusions about optimal fat intake in

pregnancy [24]. Low intake of polyunsaturated fatty acid has been associated with a small increase in risk

of some adverse pregnancy outcomes, such as preterm birth, low birthweight, and adverse

neurodevelopmental outcome. (See "Fish consumption during pregnancy" and "Prevention of spontaneous

preterm birth", section on 'Nutritional intervention'.)

Trans fatty acids (TFA) are transported across the placenta in proportion to maternal intake. TFA may

●

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Micronutrients — In the United States, the IOM and the Centers for Disease Control and Prevention (CDC)

recommend multivitamin supplements for pregnant women who do not consume an adequate diet [19,26,27].

Women at higher risk for dietary deficiencies include those who are carrying a multiple gestation, heavy

smokers, adolescents, complete vegetarians, substance abusers, and women with lactase deficiency.

Multivitamin content varies depending on the product used. At a minimum, the daily multivitamin-mineral

supplement should contain key vitamins/minerals that are often not met by diet alone, such as:

In addition to these key ingredients, pregnant women need to get adequate amounts of vitamins A, B complex,

E, C D, and zinc. Recommendations for daily intake of vitamins and minerals during pregnancy and lactation are

shown in the table (table 2). Well-nourished women may not need multivitamins to satisfy these daily

requirements, but in the absence of a careful evaluation by a nutritionist, it is prudent to recommend them.

Individual adjustments should be made based upon the woman's specific needs.

Micronutrients generally do not have a significant effect on birthweight or gestational duration in well-nourished

women. In developing countries, however, consumption of multivitamins may be beneficial. A systematic review

of 21 randomized trials of the effects of prenatal multimicronutrient supplementation on pregnancy outcome

found that low/middle income women in developing countries who received multimicronutrients had a significant

reduction in risk of SGA offspring compared with women who received iron-folate supplements (reduction in

SGA: RR 0.87; 95% CI 0.81-0.95) [28]. Multiple micronutrient supplementation had no significant effect on

maternal anemia in the third trimester compared to iron-folate supplementation alone. In a subsequent large

randomized trial, micronutrient supplements provided to Chinese women with no or mild anemia did not reduce

perinatal mortality or improve other infant outcomes [29].

Further investigation is needed to determine whether factors other than micronutrient supplementation

contributed to the reduction in SGA, which micronutrients may have the potential for improving birth weight,

whether supplementation affects other important outcomes (eg, neurodevelopment, long-term health), and the

populations most likely to benefit from this intervention. In developing countries where many births occur at

home without a skilled birth attendant, reducing the incidence of SGA could increase the risk of obstructed labor

and birth asphyxia.

Recommended daily allowances — The recommended dietary allowance (RDA) is the average daily dietary

intake of a nutrient that is sufficient to meet the requirement of approximately 98 percent of healthy persons

[30]. RDAs are different for specific age groups, males, females, and pregnant or lactating women. The RDA is

one component of the Dietary Reference Intakes (DRI), which also include Estimated Average Requirements

(EAR, ie, daily intake that meets the requirement of 50 percent of healthy persons), Adequate Intakes (AI, ie,

daily intake of healthy persons when no RDA can be determined), and Tolerable Upper Intake Levels (UL, ie,

highest average daily intake level likely to pose no risk of adverse health effects to almost all individuals in the

general population).

Calories — As discussed above, calories are the single most important nutritional factor in determining

birthweight [31]. The recommended intake is an increase in daily caloric intake by 340 kcal/day in the second

trimester and 452 kcal/day in the third trimester [32].

The United States Department of Agriculture (USDA) provides a free internet site

(http://www.choosemyplate.gov/mypyramidmoms/index.html) help pregnant women choose appropriate foods

from a food pyramid ("My Pyramid for Moms") based on their personal characteristics [33].

have adverse effects on fetal growth and development by interfering with essential fatty acid metabolism,

by direct effects on membrane structures or metabolism, or by replacing maternal intake of the cis

essential fatty acids [25]. It seems reasonable to reduce overall consumption of TFA given their adverse

effects on cardiovascular outcomes, possible adverse pregnancy effects, and lack of beneficial effects.

(See "Dietary fat", section on 'Trans fatty acids'.)

Iron – 30 mg●

Calcium – at least 250 mg●

Folate – at least 0.6 mg●

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Protein — The fetal/placental unit consumes approximately 1 kg of protein during pregnancy, with the

majority of this requirement in the last six months. To fulfill this need, the gravida should ingest 1.1 g/kg/day

protein, which is moderately higher than the 0.8 g/kg/day recommended for nonpregnant adult women [32].

Carbohydrate — The RDA for carbohydrates in pregnancy is 175 g/day, up from 130 g/day in nonpregnant

women [32].

Iron — Iron is necessary for both fetal/placental development and to expand the maternal red cell mass.

Total iron loss associated with pregnancy and lactation is about 1000 mg. The best dietary source of iron is

heme iron. Absorption of nonheme iron is enhanced by vitamin C rich foods [34].

Experts recommend an increase in iron consumption by about 15 mg/day (to about 30 mg/day) during

pregnancy to prevent iron deficiency anemia, an amount readily met by most prenatal vitamin formulations. This

is adequate supplementation for nonanemic women. Intermittent iron supplementation (one to three times per

week) appears to be as effective as daily supplementation for preventing anemia at term and is better tolerated

[35].

Although we prescribe prenatal vitamins containing iron for our patients, there is no convincing evidence that iron

supplementation in nonanemic pregnant women improves maternal or child clinical outcomes:

Women with iron deficiency anemia (first or third trimester hemoglobin [Hb] <11 g/dL or second trimester Hb

≤10.4 g/dL and low serum ferritin) should receive an additional iron supplement of 30 to 120 mg per day until the

anemia is corrected [38]. The effects of iron and folate supplementation in these women are discussed in detail

separately. (See "Hematologic changes in pregnancy", section on 'Anemia' and "Treatment of the adult with iron

deficiency anemia".)

Calcium and vitamin D

In a 2013 systematic review including 48 randomized trials (17,793 women) and 44 cohort studies

(1,851,682 women), daily prenatal iron supplementation/fortification with or without folic acid increased

maternal mean hemoglobin concentration by 4.59 g/L (95% CI 3.72-5.46) and significantly reduced the risk

of anemia (RR 0.50, 95% CI 0.42-0.59), iron deficiency (RR 0.59, 95% CI 0.46-0.79), and iron deficiency

anemia (RR 0.40, 95% CI 0.26-0.60) compared with controls taking placebo, no iron, or no iron and folic

acid [36]. Preterm birth was not significantly reduced (RR 0.84, 95% CI 0.68-1.03), but for each 1 g/L

increase in mean hemoglobin, birth weight increased by 14.0 grams and the risk of low birth weight was

reduced (RR 0.81, 95% CI 0.71-0.93). The effect of iron on birth weight requires further study as

approximately half of the trials were from low and middle income countries, where iron deficiency from poor

diet and from disease is common and therefore the benefits of iron supplementation are enhanced.

●

A 2015 systematic review for the US Preventive Services Task Force observed that routine iron

supplementation had inconsistent effects on a variety of pregnancy outcomes, but noted a consistent

reduction in the frequency of iron deficiency anemia at term (RR 0.29, 95% CI 0.17-0.49; four trials) [37].

●

Calcium – Fetal skeletal development requires about 30 grams of calcium during pregnancy, primarily in

the last trimester. This total is a relatively small percentage of total maternal body calcium and is easily

mobilized from maternal stores, if necessary. Calcium absorption increases during pregnancy and allows

progressive retention throughout gestation [39]. The RDA for elemental calcium is 1000 mg per day in

pregnant and lactating women 19 to 50 years of age (1300 mg for girls 14 to 18 years old) [40]. The dietary

recommendation for calcium is the same for lactating and nonlactating women of the same age.

●

Calcium supplementation has also been used to prevent hypertensive disorders of pregnancy. It does not

appear to be effective for healthy, nulliparous women in whom baseline dietary calcium intake is adequate.

There may be a benefit for preeclampsia prevention in high-risk populations, but further study is required

since current information is based upon small numbers of women and diverse study populations. (See

"Preeclampsia: Prevention", section on 'Calcium supplementation'.)

A 2015 systematic review found that calcium supplementation did not prevent spontaneous preterm birth

or significantly reduce the risk of low birth weight [41].

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Calcium and vitamin D deficiency — Low calcium and vitamin D levels have been associated with

adverse health outcomes in mother and child, but it is unclear whether low levels are the causal factor or a

marker of poor health. These issues are discussed in detail separately. (See "Clinical manifestations, diagnosis,

and treatment of osteomalacia", section on 'Pregnancy' and "Vitamin D and extraskeletal health", section on

'Pregnancy outcomes'.)

Folic acid

For NTD prevention — The United States Preventive Services Task Force (USPSTF) recommends that

women take a supplement containing 0.4 to 0.8 mg of folic acid one month before and for the first two to three

months after conception to reduce their risk of having a child with a neural tube defect (NTD) [44,45]. An RDA of

0.6 mg is recommended thereafter to meet the growth needs of the fetus and placenta [19]. Continuing folic acid

supplementation after the first trimester prevents the decline in serum folate and rise in homocysteine

concentrations that occur when supplementation is discontinued [46]. (See "Folic acid supplementation in

pregnancy".)

Other potential benefits — In individual trials, folic acid supplementation, usually as part of a

multivitamin, has been associated with a variety of benefits unrelated to NTDs, but these relationships require

further study and confirmation. (See "Folic acid supplementation in pregnancy", section on 'Other possible

benefits of folic acid supplementation in pregnancy'.)

Zinc — Zinc is essential for normal growth, severe zinc deficiency has been associated with growth

restriction, and observational studies have suggested that zinc supplements can increase birthweight [47].

However, in a systematic review and meta-analysis of randomized trials of the effect of prenatal zinc

supplementation greater than that recommended for daily intake during pregnancy (15 to 62 mg/day versus 11

mg), zinc supplementation had no effect on birthweight [48]. In another systematic review of 21 randomized

trials of zinc versus no zinc supplementation, zinc supplementation did not improve any outcome, except for a

14 percent reduction in preterm birth in trials that primarily involved low income women (RR 0.86, 95% CI 0.76-

0.97) and without a statistical reduction in low birthweight (RR 0.93, 95% CI 0.78-1.12) [49]. The authors

suggested that multiple social, nutritional, and medical factors were responsible for preterm birth in low income

women and probably more important targets for intervention than zinc intake.

Management of women who are at risk for severe zinc deficiency (eg, active inflammatory bowel disease,

acrodermatitis enteropathica) is discussed separately. (See "Zinc deficiency and supplementation in children

and adolescents".)

Iodine — Iodine deficiency has potentially harmful effects, such as maternal and fetal/neonatal

hypothyroidism. The IOM recommends daily iodine intake of 220 mcg during pregnancy and 290 mcg during

lactation; the World Health Organization (WHO) recommends iodine intake of 250 mcg for both pregnant and

lactating women. To achieve 250 mcg iodine ingestion daily, the American Thyroid Association recommends

that women who are planning pregnancy, pregnant, or lactating supplement their diet with a daily oral

Vitamin D – In the United States, the recommended daily allowance for vitamin D is 600 IU (15

micrograms), which can be found in some but not all prenatal vitamins [42].

●

It is not necessary to check vitamin D levels in the general population of pregnant women [43]. Women at

risk of vitamin D deficiency (table 3) can be screened with a 25-OH-D level and treated if the level is low.

The optimal level in pregnancy is unknown, but should be at least 20 ng/mL (50 nmol/L). Treatment with

1000 to 2000 international units vitamin D per day is safe. (See "Vitamin D deficiency in adults: Definition,

clinical manifestations, and treatment", section on 'Pregnancy'.)

Most commercial non-prescription products labeled vitamin D (multivitamin supplements, fortified milk and

bread) contain ergocalciferol (unactivated vitamin D2). The FDA permits non-prescription products and

supplemented foods containing either or both vitamin D2 or D3 to be labeled simply vitamin D. Prescription

products specify which form of vitamin D is supplied. Most prescription prenatal vitamins contain

cholecalciferol D3, but some contain D2 and some contain a mixture. Assuming normal renal function, the

only difference is that D3 may be more efficiently absorbed than D2. (See "Vitamin D deficiency in adults:

Definition, clinical manifestations, and treatment".)

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multivitamin supplement that contains 150 mcg of iodine in the form of potassium iodide [50]. Many prenatal

vitamins contain no iodine [51], and mild iodine deficiency has been reported in some populations, such as the

United Kingdom [52].

Adverse effects from excess supplementation — The use of self-prescribed supplements is commonplace

and has led to numerous case reports of vitamin or mineral toxicities due to overuse of over-the-counter

medicines. Specific substances identified as potentially toxic when taken in large quantities include, but are not

limited to: iron; selenium; and vitamins A (>10,000 international units per day may be teratogenic) and D (which

can cause hypercalcemia) [2,53-55].

Since some foods in the United States are fortified with vitamin A and others are rich in vitamin A (eg, liver),

pregnant women should avoid multivitamin or prenatal supplements that contain more than 5000 IU (1500 mcg)

of vitamin A. Although excessive intake of vitamin A is a concern in developed countries, vitamin A deficiency is

a concern in some developing countries. Where vitamin A deficiency is endemic, such as in Southeast Asia and

sub-Saharan Africa, a daily supplement less than10,000 IU (3000 mcg retinol equivalents) or a weekly

supplement less than 25,000 IU (8500 mcg retinol equivalents) appears to have some maternal and

fetal/neonatal health benefits (eg, reduction in maternal anemia and night blindness) with no evidence of

teratogenicity [3,56], but does not reduce maternal, fetal, or newborn mortality [57-61], which was suggested by

some early studies. Vitamin A supplementation is unnecessary where habitual vitamin A intake exceeds three

times the RDA (ie, 8000 IU or 2400 mcg retinol equivalents).

The toxic dose of vitamin D is poorly defined and vitamin D deficiency appears to be far more common than

excess intake [62,63]. A safe upper limit seems to be 100 mcg (4000 IU daily) [43]. The value of routine vitamin

D supplementation in pregnancy is an active area of investigation, but there is no clear evidence of a reduction in

adverse pregnancy outcomes (eg, preeclampsia, stillbirth, neonatal death) [64] or improvement in bone mineral

content in children [65].

Excessive quantities of iodine can cause fetal goiter. Intake of large amounts of vitamins E was associated with

congenital heart disease in one study [66], but not others [67,68].

Counseling women about common dietary issues — Self-imposed dietary restraints can be problematic if

essential nutrients are left out of the diet or weight gain is inadequate. However, certain foods should be limited

or avoided during pregnancy because of potentially toxic effects. These include consumption of some types of

fish, high caffeine intake, unwashed fruits/vegetables, unpasteurized dairy products, and undercooked meats.

(See "Epidemiology and pathogenesis of Listeria monocytogenes infection" and "Toxoplasmosis and

pregnancy", section on 'Prevention'.)

Vegetarian diet — Balanced vegetarian diets do not appear to have any adverse effects on pregnancy

outcome, although high quality evidence is scant [69,70]. These diets vary considerably, as do omnivorous

diets. The nutritional adequacy of a vegetarian diet must be judged individually, not on the basis of what it is

called, but on the type, amount, and variety of nutrients that are consumed [71].

Vegetarian diets, particularly those that exclude all animal products, may not provide adequate amounts of iron,

essential amino acids, trace minerals (eg, zinc), vitamin B-12, vitamin D and calcium, or complex lipids (eg, n-3

fatty acids) for normal embryonic and fetal development. In addition, the high bulk of food required in vegetarian

diets (especially for vegans) can make meeting energy requirements during pregnancy difficult. These

deficiencies can usually be resolved with minor dietary alterations or supplements. For example, fortified

vegetarian food products are now widely available and include some non-dairy milks, meat analogs, juices, and

breakfast cereals. These products are good sources of key nutrients, including calcium, iron, zinc, vitamin B12,

vitamin D, riboflavin, and long chain n-3 fatty acids. Individual nutritional assessment of a vegetarian’s diet with a

registered dietitian is advisable [72-75].

Vegetarian diets vary according to the degree of avoidance of foods of animal origin [76]. According to the

strictest definition, a vegetarian diet consists primarily of cereals, fruits, vegetables, legumes, and nuts; animal

foods, including milk, dairy products, and eggs generally are excluded [72,77]. Several less restrictive vegetarian

diets may include animal flesh, eggs, or milk and dairy products. Vegetarian diets frequently are grouped as

follows (less to more restricted):

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Limited research in populations outside of the United States indicated that the macronutrient intake of pregnant

vegetarians was similar to that of pregnant non-vegetarians except pregnant vegetarians consumed statistically

lower levels of protein and more carbohydrate than pregnant non-vegetarians; however, none of the studies

reported protein deficiency in pregnant vegetarians [69]. Protein consumption in the United States tends to be

significantly higher than in other parts of the world. In some Asian cultures, animal protein sources may be

consumed only once or twice a week. Although these individuals would not label themselves as vegetarian, in

American culture they would fall under the research term semi-vegetarian.

The important difference between proteins of plant and animal origin is in the concentration of indispensable or

essential amino acids. Animal foods are considered complete or high-quality proteins because they contain all

nine essential amino acids that the body needs for growth and repair of body tissues [79]. Plant-based foods are

usually incomplete, meaning that they are deficient in one or more of the essential amino acids. These

deficiencies can be corrected by use of fortified soy products, consumption of foods with complementary amino

acids, and increased intake of dairy products and/or eggs (if acceptable to the women).

Phytoestrogens consumption tends to be higher among herbivores than among omnivores. One prospective

longitudinal study suggested this exposure during pregnancy may increase the prevalence of hypospadias in

male offspring [80].

Preventing atopic disease in offspring — Avoidance or ingestion of specific antigens, such as peanuts,

has been suggested during pregnancy to reduce the frequency of atopic disease in offspring, but the bulk of

evidence does not support either approach. These diets should not be recommended; women should consume

their usual diets. (See "Primary prevention of allergic disease: Maternal avoidance diets in pregnancy and

lactation".)

On the other hand, breastfeeding may reduce the risk of allergic disease in offspring. (See "The impact of

breastfeeding on the development of allergic disease".)

Gluten-free diet — In a systematic review of case–control and cohort studies, women with untreated celiac

disease were at increased risk of reproductive failure compared with women in the general population [81].

Treatment with a gluten-free diet eliminated the excess risk of these complications. (See "Pathogenesis,

epidemiology, and clinical manifestations of celiac disease in adults", section on 'Menstrual and reproductive

issues'.)

Although gluten-free diets are popular and promoted in the lay press for their health benefits, there is no

evidence that following a gluten-free diet has any significant health benefits in women without celiac disease or

gluten sensitivity [82,83]. Elimination of gluten-rich foods during pregnancy could result in inadequate intakes of

Semi-vegetarian – People who consume meat, fish or chicken in their diet on occasion. Some people who

follow such a diet may not eat red meat, but may eat fish and perhaps chicken. This identification is used

mainly in research studies.

●

Pescatarian – Vegetarian whose diet includes fish on occasion in addition to eggs, milk and milk

products, but no other animal meats.

●

Lacto-ovovegetarian – Eggs, milk, and milk products (lacto = dairy; ovo = eggs) are included, but no meat

is consumed.

●

Lactovegetarian – Milk and milk products are included in the diet, but no eggs or meat are consumed.●

Macrobiotic – Whole grains, especially brown rice, are emphasized and vegetables, fruits, legumes, and

seaweeds are included in the diet. Locally-grown fruits are recommended. Animal foods limited to white

meat or white-meat fish may be included in the diet once or twice a week.

●

Vegan – All animal products, including eggs, milk, and milk products, are excluded from the diet. Some

vegans do not use honey. They also may avoid foods that are processed or not organically grown [78].

●

Fruitarian – Vegan diet based on fruits, nuts and seeds. Vegetables classified botanically as fruits

(avocado, tomatoes) are commonly included in fruitarian diets; all other vegetables, grains, beans and

animal products are excluded.

●

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thiamin, riboflavin, niacin, folate, and iron; however, substitution of other whole grain foods should prevent any

nutritional deficiency and these diets are generally considered safe.

Lactose intolerance — Women with lactose malabsorption appear to handle lactose better in late

pregnancy [84,85]. This has been attributed to slower intestinal transit during pregnancy and bacterial

adaptation to increased lactose intake. For women unable to consume adequate amounts of calcium through

dairy and other dietary components, calcium supplements can be prescribed. There are no data on the safety of

commercially available "lactase" preparations during pregnancy; however, beta-galactosidases are normal

constituents of human tissues.

Fish intake — Methylmercury exposure, primarily through ingestion of contaminated fish, can cause severe

central nervous system damage, as well as milder intellectual, motor, and psychosocial impairment. For this

reason, the FDA and Environmental Protection Agency (EPA) recommend that pregnant women (or woman who

might become pregnant or who are nursing) should:

Tuna steaks should be limited to 6 ounces per week. Many physicians recommend that pregnant women avoid

eating any tuna steaks because large tuna can have high mercury levels. Canned tuna is made from smaller

fish, which typically have lower levels of mercury.

These thresholds were based upon limited data and may reflect adverse effects noted in studies in which

pregnant women had high intake of fish with high mercury concentrations (whale 1.6 mcg/g [86,87] and shark

2.2 mcg/g [88,89]). Different findings were reported in a study of women from the Seychelles, who averaged 12

meals per week of ocean fish with lower mercury concentrations (0.3 mcg/g, similar to that in fish consumed by

American women) [90]. This study did not find significant cognitive or behavioral effects in offspring of women

with high fish consumption when other factors, such as social and environmental developmental modifiers and

postnatal mercury exposure, were considered. These results are reassuring that women who consume a variety

of ocean fish probably do not have to reduce intake during pregnancy [91]; however, the governmental

recommendations cited above remain in effect. The risks and benefits of prenatal and postpartum fish

consumption are reviewed in detail separately. (See "Fish consumption during pregnancy".)

Contamination of fresh water fish varies with locale; the EPA and local health departments provide advice on fish

consumption from fresh water lakes and streams (for current information, contact the Environmental Protection

Agency at 1-888-SAFEFOOD or view the internet site www.epa.gov/waterscience/fishadvice/advice.html).

Information from the FDA is accessible through the FDA food safety website.

A more detailed discussion of potential adverse effects of various mercury compounds, including dental

amalgams, can be found separately. (See "Epidemiology and toxicity of mercury".)

Pregnant women are advised to eat only cooked fish in order to avoid potentially harmful organisms; however,

appropriate freezing of raw fish [92] eliminates most parasites and bacteria so pregnant women who have

consumed "sushi grade" raw fish can be reassured that this is generally safe [93]. A variety of marine toxins

(eg, ciguatoxin) can be ingested via fish consumption (cooked or raw), but there are only rare reports of adverse

effects on pregnancy or the fetus. (See "Overview of shellfish and pufferfish poisoning".)

Caffeine intake — Observational studies have reported a association between caffeine intake (table 4) and

Avoid eating any shark, swordfish, king mackerel, or tilefish because they may contain high levels of

mercury.

●

Eat up to 12 ounces (two average meals) a week of a variety of fish and shellfish that are lower in mercury.

Commonly eaten fish that are low in mercury include shrimp, canned light tuna, salmon, pollock, and

catfish. Albacore (white) tuna has more mercury than canned light tuna, therefore consumption of albacore

tuna should be limited to 6 ounces (one average meal) of the total. Specific information on levels of

methylmercury in other species is available through the FDA food safety website or the EPA website at

www.epa.gov/waterscience/fish/.

●

Check local advisories about the safety of fish caught in local lakes, rivers, and coastal areas. If no advice

is available, up to 6 ounces (one average meal) per week of fish caught in local waters may be consumed,

but additional fish consumption should be avoided that week.

●

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several adverse pregnancy outcomes, including miscarriage, preterm birth, and impaired fetal growth. A

limitation of these studies is their inability to adjust for confounders or accurately measure caffeine intake, which

depends upon the size of the cup, brand of coffee, and brewing method. Given the limitations and

inconsistencies of available data, it may be prudent for women who are attempting to conceive or who are

pregnant to limit caffeine consumption to less than 200 to 300 mg per day to potentially reduce their risk of

possible adverse reproductive effects.

The effects of caffeine on pregnancy outcomes are discussed in detail separately. (See "The effects of caffeine

on reproductive outcomes in women".)

Use of artificial sweeteners — There is no evidence that use of aspartame (Nutrasweet), sucralose

(Splenda), saccharin (Sweet 'N Low), acesulfame potassium (Sunnet), or stevioside (Stevia) by pregnant women

increases the risk of birth defects above the baseline risk in the general population [94]. One study showed an

increased risk of bladder cancer in offspring of pregnant rats that consumed very high doses of saccharin; the

only other study did not show an increased risk. In addition, saccharin is eliminated much more slowly in the

fetus than in the adult [95]. Since there are alternatives to using saccharin, some clinicians recommend avoiding

it in pregnancy.

A task force of the American Academy of Pediatrics' (AAP) Committee on Nutrition concluded that aspartame is

safe for both the pregnant mother and developing baby. In addition, the FDA and the Council on Scientific Affairs

(CSA) of the American Medical Association (AMA) concluded that women who are pregnant or breastfeeding

can safely use aspartame [96]. Although methanol is a breakdown product of aspartame, methanol is also

produced as a breakdown product of many fruits; the levels produced from either of these sources are very low

and considered safe in pregnancy.

The Acceptable Daily Intake (ADI) is defined as an estimate of the amount of a food additive that can be

ingested daily over a lifetime without appreciable health risk. Average use of artificial sweeteners is usually

below this limit. For example, the ADI for aspartame is 50 mg/kg/day; Diet Coke contains 131 mg aspartame

per 355 mL can and one packet of Equal contains 33 mg of aspartame. The FDA recommends that pregnant

women limit consumption of aspartame to a moderate level. The ADI for saccharin and sucralose is 5

mg/kg/day, for acesulfame potassium it is 15 mg/kg/day, and for stevioside it is 4 mg/kg/day.

Fluoride intake — Theoretically, pregnant women who live in areas where water is not fluoridated, or who

consume only unfluoridated bottled water, may not achieve adequate intake of fluoride, which is 3 mg/day in

nonpregnant, pregnant, and breastfeeding women [97,98]. Fluoride intake is difficult to determine, given that

fluoride may present in liquids used in bottled drinks and prepared foods (eg, soups, canned vegetables) and is

present in tea and seafood that contains edible bones or shells (eg, canned sardines).

Fluoride supplementation is not recommended during pregnancy [99]. Prenatal fluoride supplementation is not

incorporated into primary teeth [100] and does not reduce caries in offspring [101]. The benefits of fluoride occur

almost entirely after tooth eruption as a direct topical effect on teeth; earlier hypotheses that ingested fluoride is

systemically incorporated into developing tooth enamel have been largely discredited as a primary mechanism

of fluoride action [102,103]. There is good evidence that postnatal exposure of newly erupted teeth to topical

fluoride from water or dentifrice is efficacious [102,103]. Excess ingestion of fluoride during pregnancy does not

appear to produce fluorosis in offspring [104], probably because the placenta provides a selective barrier to

transfer of excess fluoride [105]. (See "Overview of dietary trace minerals" and "Preventive dental care and

counseling for infants and young children".)

Fasting — Pregnant women may fast for several hours during the day, for one or more days, for religious or

other reasons. During an overnight 12- to 18-hour fast, plasma glucose, insulin, and alanine levels fall, and

plasma free fatty acids and beta-hydroxybutyrate levels rise, a phenomenon termed “accelerated starvation”

[106]. With early conversion to fat metabolism, other fuels, such as glucose and amino acids, are more

available for the fetus. Free fatty acids and beta-hydroxybutyrate are also transferred across the placenta and

metabolized by the fetus.

The effects of daytime fasting in otherwise healthy pregnant women are not well-defined. In ovine and human

studies, the most consistently reported effect of fasting is reduction in fetal breathing movements, with

resolution in the fed state [107-111]. There is no information on the effect of ketonuria on fetal/neonatal outcome

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in the absence of ketoacidosis. Studies of pregnancy outcome in healthy women who fasted during the month of

Ramadan have generally not reported adverse fetal effects [112-118]. However, some authors have hypothesized

that prolonged fasting during pregnancy can lead to permanent alterations to fetal physiology that have

consequences in adult life [119].

Consumption of liver-based foods — High vitamin A intake from consumption of liver or liver-based foods

(eg, patties, sausage) may be harmful and some groups (eg, Finnish Food Safety Authority, March of Dimes,

National Health Service) have recommended that pregnant women limit or avoid liver consumption for this reason

[4-9].

Unpasteurized milk — Unpasteurized milk and dairy products may contain pathogens that could lead to

maternal, fetal, and neonatal infection; miscarriage; preterm birth, and stillbirth. These products should be

avoided [120].

Raw or undercooked meat, unwashed fruits and vegetables, cold processed meats — Contamination

of these food products by bacteria or parasites can lead to maternal, fetal, and neonatal infection, with

potentially serious sequelae. (See 'Avoidance of foodborne illnesses' above.)

MULTIPLE GESTATION — Women carrying a multiple gestation should increase their daily dietary intake.

Guidelines are provided separately in the topic review on management of twin gestation. (See "Twin pregnancy:

Prenatal issues", section on 'Pregnancy counseling and management'.)

HERBAL PRODUCTS AND ALTERNATIVE THERAPIES — Use of herbal therapies is common; two large

studies including a total of over 8000 women in the US found that 5 to 10 percent reported herbal use during

pregnancy [121,122]. The most common products were herbal teas, chamomile, ginger, echinacea, and

ephedra. Surveys conducted in Europe, Australia, and the United States indicate 7 to 45 percent of pregnant

women use herbal products [123]. Daily abdominal application of almond oil to alleviate stretch marks was

common in Italy and associated with an increased risk of preterm birth [123].

There are limited randomized trials evaluating the efficacy and safety of traditional herbal preparations in

pregnancy [124]. Some practitioners suggest patients take herbal supplements to help alleviate symptoms of

pregnancy (eg, nausea), prevent or treat obstetrical complications (eg, miscarriage, preterm birth,

preeclampsia), or ripen the cervix or induce labor at term [125-127]. There is a lack of consensus on the

appropriate dose and administration of these preparations. The best evidence is for use of ginger in the

treatment of morning sickness. (See "Treatment and outcome of nausea and vomiting of pregnancy".)

We recommend avoiding use of herbal medicines in pregnancy [128,129]. The practitioner has no control over

the strength or purity of the individual herbs; herbal preparations can interact with commonly prescribed

medications and lead to dangerous side effects [130,131]; and several cases of potentially harmful effects to the

pregnancy have been reported [132-134]. (See "Overview of herbal medicine and dietary supplements".)

POSTPARTUM AND BREASTFEEDING — An adequate, balanced diet is important for replenishment of

maternal stores that are expended during the pregnancy, for promoting loss of excess weight, and for nourishing

the breastfed infant.

Postpartum weight changes — Retention of pregnancy-related weight gain is a problem for many women and

has contributed to the obesity epidemic in developed countries. Diet and exercise can help women lose weight

postpartum and appear to be safe, even in breastfeeding women. (See "Overview of postpartum care", section

on 'Postpartum weight retention'.)

Breastfeeding — Women who are breastfeeding should increase their daily caloric intake by 300 to 500 kcal

above prepregnancy levels and consume 1000 mg/day of calcium [135]. Theoretically, this level of caloric intake

should mobilize the excess fat stored antepartum and promote modest weight loss, since the caloric demand of

lactation is estimated at 640 kcal/day [136]. In practice, however, lactation has a variable effect on maternal

weight [137,138]. (See "Maternal nutrition during lactation".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and

“Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6 grade

reading level, and they answer the four or five key questions a patient might have about a given condition. These

th th

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articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond

the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are

written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are

comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these

topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on

“patient info” and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS

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REFERENCES

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"Patient information: Nutrition before and during pregnancy (The Basics)")

●

Beyond the Basics topics (see "Patient information: Maternal health and nutrition during breastfeeding

(Beyond the Basics)")

●

The United States Preventive Services Task Force (USPSTF) recommends that women take a folic acid

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●

Women with metabolic diseases (eg, diabetes mellitus, phenylketonuria) should try to normalize abnormal

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●

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●

Body mass index (BMI) <18.5 kg/m2 (underweight) – weight gain 28 to 40 lbs (12.5 to 18.0 kg)•

BMI 18.5 to 24.9 kg/m2 (normal weight) – weight gain 25 to 35 lbs (11.5 to 16.0 kg)•

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●

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●

Pregnant women should reduce consumption of some fish to minimize fetal exposure to mercury and other

water borne contaminants. (See 'Fish intake' above.)

●

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