"Intra-uterine growth retardation" is the term used when the baby is not growing as much as it should be. Babies who are smaller than they should be at this stage of the pregnancy are called "small for gestational age" (SGA).

If you are going to a midwife, she has been measuring your belly every visit, from your pubic bone to the top of your uterus (the top is called the "fundus"). The measurement is taken in centimeters (cm), and the number of cm of your measurement should equal the number of weeks of pregnancy (gestation) that your baby is, plus or minus 1-2 cm.

When a baby is smaller than s/he should be for her/his gestational age, one of the first things that a midwife should look for is whether you have been eating enough of the right kinds of foods, because the only way the baby can grow is by taking in nutrients that come to her/him through the umbilical cord, and those nutrients can only come from foods that you eat. Contrary to the beliefs of some, the baby cannot create the nutrients that s/he needs from the mother's body fat.

See here for a diet adjustment that can help turn an IUGR situation around

You can also refer to the "Bad Placenta?" story on the "Stories" page of this website for a dramatic account of how a SGA baby was rescued by her mother's use of the Brewer Diet.

See here for the "Bad Placenta?" story

See here for "Turning IUGR Around With Creativity, Determination, and Vegetarian Protein"

See here for more information on how the over-medicalization of normal childbirth can cause low birth weight

At the first sign of a rising BP, pathological edema, pre-eclampsia, IUGR, premature labor, or HELLP, a Brewer Diet counselor should sit down with the mother and help her to evaluate her lifestyle and her diet to see if any adjustments can be made to optimize the fit between her pregnancy, her diet, and her lifestyle. For example, to compensate for her salt and calorie losses, she can cut back on her exercise program and her work schedule, she can stay out of the heat (outdoors, at work, or at home), she can postpone a move until after the birth (and 6 weeks postpartum), and she can increase her salt/calorie/protein intake. One way that she can increase her diet intake is to add 200 calories and 20 grams of protein for each of the following situations:

The above information is reprinted and adapted from the work of Agnes Higgins, and Gail Brewer's "The Complete Pregnancy Diet: Meeting Your Special Needs" from Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.

See here for more information on adjusting the Brewer Diet to fit your lifestyle

Eating for Two, by Gail Sforza Brewer and Isaac Cronin, available here

Please be aware that traveling and moving can break up your eating routine just enough to trigger a low blood volume problem which can start the rising BP/pre-eclampsia/HELLP/premature labor/IUGR/abruption process. Putting the brakes on that process can be more difficult than preventing it. Sometimes just being aware of this danger is enough to help you to remind yourself to continue providing for your nutritional needs, in spite of any changes and stresses which may be going on in your life.

Five Minute Lesson in Preventive Obstetrics
Tom Brewer, MD
12-12-1980

There are two central facts which need emphasis:

1. The human placenta creates an ARTERIO-VENOUS SHUNT (A/V) in the maternal circulation. During the last trimester of normal pregnancy, 50 to 60 jets of arterial maternal blood spurt up against the fetal cotyledons with each maternal cardiac systole. This blood swirls about in the intervillous space and passes via "tub drains" back into the uterine venous system.

2. The A/V shunt requires for optimal fetal growth and development an INCREASING MATERNAL BLOOD VOLUME throughout the second trimester to a plateau which must be maintained throughout the entire third trimester.

Failure to recognize these two well-established facts has created havoc in human maternal-fetal health throughout the whole western world, especially in the USA, Canada, and the United Kingdom. The observed reduction in utero-placental blood flow associated with common human reproductive pathology has not been correctly interpreted as the result of hypovolemia, failure to maintain a physiological expansion of maternal blood volume.

Physicians commonly carry out dietary restrictions of calories and sodium and give drugs, diuretics, sodium substitutes, anorexiants, vasodilators etc. which actually cause and/or enhance maternal hypovolemia. Intrauterine fetal growth retardation (IUGR) and small for gestational age (SGA) babies have increased dramatically since the 1950s, especially in these three nations, where the role of prenatal malnutrition in causing human reproductive casualty in still universally denied by medical authorities. Applied physiology and basic nutrition science in human prenatal care as a routine for all women all through gestation much form the basis of true, primary prevention in this field.

See here for an illustration of the placenta and the a-v shunt which creates the lake of maternal blood

The following questions and answers regarding IUGR are from The Brewer Medical Diet for Normal and High-Risk Pregnancy, by Gail Sforza Brewer (Krebs) and Tom Brewer, MD.

But if I salt my food to taste for nine months, won't that cause a lot of swelling from excess water retention? Many women cut out all added salt during the last few days of their menstrual cycles, anyway, because it helps get rid of that bloated feeling. Aside from the discomfort, isn't swelling a danger sign in pregnancy? (p. 48)

Note from Joy: See paragraph #6 for explanation of IUGR.

It certainly can be a danger sign--but only when the swelling is caused by not eating enough of the right foods (including sodium-rich ones) or by a medical condition that would cause swelling in a non-pregnant woman or a man as well, such as heart failure or kidney disease.

The swelling that accompanies the normal course of pregnancy while you are on the Brewer Medical Diet is attributable to an entirely different cause--your healthy, well-functioning placenta. The same hormones that you've noticed make you swell up somewhat just before your period (some women hold an extra 5 to 7 pounds of water) are made in ever-increasing amounts by your placenta as pregnancy goes along. By the eighth month, in the well-nourished mother, the placenta makes--every day--the equivalent of the hormones in a hundred birth control pills! This swelling is not hazardous to you or to your baby. In fact, it's a natural way for your body to prepare for labor and breastfeeding by storing fluids you may need to avoid dehydration if your labor lasts a long time and to establish and maintain quality milk production.

Though all swelling may look the same, the situation inside your body is critically different when you are swelling on a good diet. On a nutritionally sound diet your liver has all the building blocks it needs to manufacture adquate amounts of a protein, albumin, that holds water in your circulation--the primary means by which your increased blood volume needs are met during pregnancy. The larger volume of nutrient-rich blood servicing your placenta results in the larger production of female hormones and, so, more water retention than in a mother with average nutrition. It is possible for your tissues to hold 10 to 15 pounds of fluid for this reason without causing much change in your appearance--perhaps the fine lines in your face disappear and your rings feel somewhat tighter.

This "hidden" water retention in the well-fed pregnant woman (plus the increased size of her baby) has seldom been accounted for in the charts that break down the components of average weight gain in pregnancy, so they typically show a total of 24 to 28 pounds, whereas women on the Brewer Medical Diet gain, on the average, 35 to 45 pounds. Of course, many women gain less and many gain more based on their prepregnancy weights, metabolism, and activity level. We do not use the average as a rule (either a floor or a ceiling) for weight adjustment in pregnancy; it only demonstrates that the average figure you see elsewhere fails to consider the additional, beneficial water retention that comes with a good diet.

When your diet is not meeting your nutritional needs, the internal events are exactly the opposite. If the liver is undersupplied with the nutrients needed to produce albumin (and this is one of the most complicated functions the liver performs, so it's one of the first to go when nutrients are scarce), it cuts back. This decrease in production is detectable by analyzing a sample of blood: anything below 3 grams per 100 cubic centimeters of serum indicates a problem. With less albumin circulating and drawing water into the circulation, water that should be held inside your blood vessels cannot stay there. Instead, it leaks out into your tissues. Voila! You're swelling up, and the scales tell you about the water you're retaining--but they don't tell you where it is. Nor do they tell you that your blood volume is falling below the needs of a healthy pregnancy and that your placenta is starting to malfunction because of the reduced amount of blood flowing through it.

The pregnant woman on a poor diet (or even one on a basically nutritious diet who is not eating enough to meet her calorie needs) is not swelling from the influence of an increase in female hormones generated by a generous, healthy placenta. She is experiencing a shift of essential body fluids out of her circulation and into her tissues. If the situation continues, her other critical body organs, like the kidneys, liver, heart, lungs, and brain, become adversely affected by the dwindling blood supply (the kidneys respond, for example, by raising the blood pressure), and her baby begins to suffer intrauterine malnutrition. Most commonly this situation is diagnosed after a few weeks when the baby's failure to grow is noted at subsequent prenatal appointments. The medical terminology for this condition is intrauterine growth retardation (IUGR). If caught early enough, the situation can be reversed with appropriate nutritional intervention--by getting the mother on a diet suitable for her pregnancy needs and keeping her on it for the rest of her pregnancy. This includes salting to taste.

This interconnection between the foods you eat, how your liver works to keep your blood volume expanded, and the transfer of nutrients to your baby via the placenta is central to every successful pregnancy. It is impossible for anyone to evaluate what's happening internally from looking at your swelling or pressing your shinbone to see if you have water retention. Laboratory work measuring your blood proteins and hematocrit reading must be done before any diagnosis is made.

Swelling on a good diet is a sign of health in pregnancy. So salt to taste as an integral part of your pregnancy nutrition program. Do not restrict salt. Do not take diuretics or appetite suppressants to control your weight. Any of these actions is a direct attack on the expansion of your blood volume and places you and your baby in jeopardy for the most serious pregnancy complications.

Note from Joy: While the use of amphetamines and diuretics may no longer be considered the mainstream treatment of choice for the symptoms of toxemia, other methods of weight control in pregnancy and treatments for toxemia are currently in vogue which are equally hazardous to both the baby and the mother. And unfortunately, the hazards of these current treatments are no more recognized by the mainstream practitioners of today than were the hazards of the earlier use of amphetamines and diuretics by the practitioners of yesterday. I have been witness to some of the current hazardous treatments, just within the past 5-10 years.

I worked for a homebirth midwifery practice for several years. For most of that time, all the midwives were supportive of the use of the Brewer Diet by the clients of the practice. The last year of my time there, we got a new midwife on staff who was very opposed to the use of the Brewer Diet. Whenever we got a new client who was the least little bit on the plump side, she would apparently tell her to get a little more exercise and eat a little less carbohydrates. When her blood pressure would start to creep up, she would tell her to cut back on her salt a little bit. No amount of my trying to explain the Brewer insights to her made any headway. As a result, within the first six months of her being on staff, we had 2-3 clients who had to be hospitalized with blood pressure problems and premature labor, as I recall, which was very uncharacteristic of our practice.

So it is very important that we not dismiss the historical accounts that Brewer has documented for us. We need not look down our noses at his reports of the starvation-amphetamine-diuretic practices of the physicians around him in his early days, and his efforts to stop those practices. We have our own faulty treatments in our own time, which are based on the same faulty thinking, and are just as hazardous as the treatments that he witnessed.

In addition, unfortunately, some areas of the "alternative medicine" community have apparently followed mainstream medicine in the belief that diuretics are important and useful for treating edema and elevated blood pressure in pregnancy. Many pregnancy teas and some supplements and juices include nettle, dandelion, alfalfa, bilberry, or celery, all of which have diuretic properties. Diuretics are no safer for pregnancy in herbal form than they are in prescription medications, so it is important for pregnant women to watch which herbs they are taking.

See here for more information on the hazards of using herbal diuretics in pregnancy

"Forty Weeks, Forty Problems" (pp 162-163)

I had ultrasound scans at twenty-four and twenty-eight weeks because my family doctor was having trouble deciding whether my baby was growing normally.

There didn't seem to be much change in the size of my uterus from twenty weeks to twenty-four weeks. The scan done at twenty-eight weeks shows that my baby is only the size of a twenty-three week pregnancy. My doctor wants me to travel a hundred miles to a high-risk pregnancy unit at our state medical school hospital and be admitted for tests. I just found out about your diet and I know I haven't been eating anywhere near that amount of food. If I start eating better now, will my baby catch up, or is it too late?

You still have the last twelve weeks of pregnancy to go--the time when your baby puts on weight most rapidly--so yes, catching up is possible, assuming you haven't been severely limiting your food intake up until now. In some cases where the growth of the placenta has been impaired because of very poor diet, the recovery period for the baby is not so successful--no matter how well you eat toward the end of your pregnancy. There is less placental mass and a reduced capacity to transfer the nutrients you are suddenly providing from the foods that you eat.

We are always optimistic about efforts to improve the feeding of pregnant women, though, based on the work of Leela Iyengar, M.D., of India published in this country in 1968. She brought women diagnosed as malnourished into the hospital and fed them over the last four weeks of pregnancy. The birth weights of babies born to these mothers were a full pound more, on the average, than those of babies whose mothers were also identified as malnourished but were not provided supplemental feeding. Placental function, measured by excretion of estrogens in the urine, also improved dramatically following the improvement of the mothers' nutritional status.

So don't despair. Chances are good that you can do a great deal for your baby during these next three months, especially since this is the critical period of time for the development of your baby's brain. It used to be thought that everything of significance in organ formation happened in the first three months of gestation, but much work now points to the last eight to ten weeks of pregnancy as another time when even mild degrees of maternal undernutrition can prevent the brain from developing normally.

There are some nonnutritional causes for intrauterine growth retardation that your doctor probably would like to rule out as being of signigicance in your case (hence, the tests in the regional high-risk center). Infections your baby may have acquired in utero, abnormalities of the placenta and/or cord, and abnormalities of the baby's chromosomes or heart can also cause your baby to be small for gestational age (SGA). However, before you enter the hospital for the series of tests, give improved nutrition a try for two or three weeks and then ask for a reappraisal of your situation. Explain to the doctor that you don't think you've been eating well enough and you'd like to see if a trial of improved nutrition will bring about increased growth. Since there is nothing to be done for the nonnutritional causes for SGA babies, you have nothing to lose by waiting.

Salt in Pregnancy

	High Salt Diet	Low-Salt Diet
Toxemia	37/1000	97/1000
Perinatal deaths	27/1000	50/1000
C-section	9/1000	14/1000
Abruptio placenta	17/1000	32/1000

The series of tests at the high-risk unit would probably also include an evaluation of your kidneys, cardiovascular system, any nonnutritional anemias, and the presence of any other medical diseases that might require treatment. You will also be asked about your smoking, drinking, and hard drug habits, all of which can be associated with a slower rate of fetal growth primarily because they substitute for eating.

There is one last factor to be considered. Are you sure of when you conceived? If you became pregnant while breastfeeding and hadn't truly resumed normal periods, or if you became pregnant immediately after stopping birth control pills, you may not be as far along as your chart says. In either case, all you can do now is to start eating correctly every day to see if you can bring your baby at least up to appropriate weight for weeks of gestation.

Nutritional Deficiency in Pregnancy

Complications	Control Group (750)	Nutrition Group (750)
Preeclampsia	59	0
Eclampsia	5	0
Prematures (5 lb. or less)	37	0*
Infant Mortality	54.6/1,000	4/1,000

From a previous question regarding dates, ultrasound scans, and nutrition (pp 155-156).......

A repeat scan will detect any failure of your baby to grow (intrauterine growth retardation, or IUGR). However, measuring the height of your uterus, a time-honored way of appraising fetal growth, can also sound the alert. Any time it is suspected, of course, the treatment for IUGR must include a complete nutritional workup and correction of any deficiencies. All too often, the mother is just assigned to a high-risk category, shifted to the care of a high-risk specialist until her underweight and sickly infant is born, and her nutrition fades into the background as a battery of tests are ordered many times over.

The Brewer Medical Diet for Normal and High-Risk Pregnancy available here

The following is reprinted from "Chapter 1" of Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.

"The Complete Pregnancy Diet: Meeting Your Special Needs", by Gail Sforza Brewer (p.1)

CORRECTIVE ALLOWANCES

Agnes Higgins, past president of the Canadian Dietetic Society and director of the Montreal Diet Dispensary [as of 1983], has developed a procedure for estimating calorie and protein requirements in excess of the pregnancy levels we've already established as a baseline. She emphasizes that any of the following factors increases a mother's nutritional needs:

As a corrective allowance, Mrs. Higgins and her staff counsel mothers to add twenty grams of protein and two hundred calories to their basic daily pregnancy diets for each condition listed above (an individual mother may be experiencing more than one of these stress conditions).

Multiple pregnancy is the only exception: each extra baby requires a nutritional supplement of thirty grams of protein and five hundred calories per day. Higgins comments that this requirement can be met most economically by adding one quart of whole milk a day to the expectant mother's diet (to be drunk, used in cream soups, custards, milkshakes, cream pies and tarts, or as exchanges in yogurt, ice milk, and natural cheeses). Of course, there are many other ways to increase the protein and calories during pregnancy by eating an additional four-ounce serving of meat, fish, shellfish, poultry, or meat substitute as detailed on the diet list. A sample daily menu plan for a mother expecting twins would look something like this:

Generally speaking, these conditions result in an increased appetite; however, women who are working, moving their households, or under emotional stress sometimes fail to pay attention to their bodies' signals for more food. Calling special attention to their extra needs by assigning specific goals for extra protein and calorie consumption makes it much less likely that their nutritional needs will go unfulfilled.

Undernutrition means any protein deficit between what you're used to getting from your food and the minimum adequate pregnancy requirement (eighty to a hundred grams per day). The Higgins nutrition intervention method uses a twenty-four hour diet recall, a technique you can use on your own to see how close your regular diet has been coming to what you actually need. You will need to write down everything you've eaten for the past twenty-four hours (pick a typical day for you), including all snacks, all beverages, and all second helpings. Note what the food was, how much you ate, then consult the Protein-Calorie Counter (see Appendix) to check the amount of protein contained in those portions of those foods. For each gram of protein you lack, add that to your personal protein goal, plus an additional ten calories to free that protein for its most important work in pregnancy: keeping you own tissues healthy and building those of your unborn baby. If you come up with a deficit of ten grams of protein, then, you also need to add a hundred calories to your basic requirements.

See here for entire chapter, "The Complete Pregnancy Diet: Meeting Your Special Needs"

Eating for Two, by Gail Sforza Brewer and Isaac Cronin, available here

Placenta

As Figure 8 shows, it is also the action of your uterus that separates your placenta and expels it in the third stage of labor. This organ allows nutrients and oxygen to pass from your bloodstream into your baby's and also permits the removal of waste products from the baby's body. The placenta originated in cells from the fertilized egg. Enzymes on the surface of the ovum dissolved away a tiny portion of the surface of your uterine wall, opening a few arteries and veins in the process. With each beat of your heart, from that moment until your placenta comes away from the wall of your uterus, those arteries spurt jets of nutrient- and oxygen-rich blood against the surface of the placenta. This is the only blood supply to this most important organ, and only what is present in your bloodstream can nourish it and your developing baby.

The placenta is firmly anchored to the wall of your uterus by threads of collagen throughout and by a seal around its margin. Because of this, the blood that swirls up against the placenta stays in a "lake," continuously bathing the placental tissue. This blood does return to your heart after spending some time in the "lake," via the open veins that now function like the drain in you tub or shower stall: the pooled blood is pushed into the veins by the force of new blood coming into the "lake" from the open arteries. Technically, this sort of blood supply is termed an a-v (arterio-venous) shunt, meaning that the blood passes directly from arteries to veins without first passing through capillaries (the usual way things are done in the body).

Since the supply of blood encourages and supports placental growth, and a larger placenta requires more blood to keep it functioning optimally, ever-increasing amounts of blood are required as pregnancy advances to satisfy the needs of the placenta. If you are carrying a single baby, your blood volume will expand approximately 60 percent (if you eat well enough) to service your placenta. If you have twins (and therefore a double placenta or two separat placentas), your blood volume must expand by 100 percent or more to stay even with the demand. A falling blood volume or a blood volume that is below the needs of your pregnancy is recognized as a major cause of premature labor, underweight babies, and high blood pressure during pregnancy. When you recognize the importance of keeping your blood volume up and your placenta healthy (even though you can't see it or feel it), you will have a strong inducement to stay on your excellent pregnancy diet every day.

See here to better understand the evolution of the mainstream medical perspective on nutrition and salt in pregnancy

Nine Months, Nine Lessons available here

The following is reprinted from Medikon International no. 4 - 30-5-1974.

"Iatrogenic Starvation in Human Pregnancy", by Tom Brewer, M.D., County Physician, Contra Costa County Medical Services, Richmond, California, U.S.A.

[Iatrogenic = Induced inadvertently by a physician or surgeon or by medical treatment or by diagnostic procedures]

Frank Hytten tells us in his pregnancy physiology textbook of two pioneers in the field of iatrogenic starvation in human pregnancy.(1) A certain Professor Brunninghausen of Wurzburg decided, for reasons unstated, that it was better for women to eat less food during pregnancy; this was in 1803. A century later Prochownick is given credit in 1899 for introducing the idea that caloric and fluid restrictions during human pregnancy could produce an infant who weighed less at birth.(2) The intention of Prochownick was to minimize the cephalopelvic disproportion in a woman with a borderline contracted pelvis and thus reduce the incidence of surgical intervention in such patients. As surgical techniques developed with the practices of asepsis and improved anesthesia established, Western European obstetricians lost all fear of operative delivery. Prochownick's valuable clinical observation that caloric and fluid restrictions do in fact lower the birth weight of the newborn human infant was forgotten. Thus a very important clue to the mystery of "low birth weight for dates" newborns was buried.

Unfortunately, this still universal misconception became established as a dogma in clinical obstetrical teachings in Western medical culture: the human fetus is a parasite, will grow according to its "genetic code" to a given weight and length before birth, and that this growth and development are in no concrete, material sense influenced by the foods and fluids the pregnant woman is taking in during the course of her gestation.(3,4) Scientific obstetrics still suffers today from what I term "nutritional nonchalance" related to this false belief.

In 1972 officially in the United States the cause of eclampsia, the disease I term convulsive metabolic toxemia of late pregnancy (MTLP), was "unknown."(5,6) [This official assertion continues into 2008] Since this dread disease remains a common cause of maternal, fetal and newborn morbidity and mortality throughout the world, speculations about its etiology continue. It has been long believed that the Nutrition of the pregnant woman during gestation does in fact influence her development of MTLP. Women who develop MTLP are still accused of eating too many calories and too much salt (NaCl). That such an idea remains popular in 1973 stems from the fact taht very few Western-trained OB/GYN surgeons have ever taken time or interest to ask these poor women what foods and how much they have been eating and drinking during pregnancy.

When I began to work in the Tulane Service's prenatal clinics at Charity Hospital, New Orleans, Louisiana, as a third year medical student, pregnant patients were being told to restrict their caloric intake and to restrict their dietary salt intake: "So you won't have fits....so you and your baby won't die from toxemia." It is difficult for me to learn what is happening there now since no members of the Tulane faculty will communicate with me, but unofficial sources informed me not long ago that "...nothing has changed in this field since you were here over 20 years ago." I studied this problem for four years in another city-county hospital in our deep south. Jackson Memorial Hospital, Miami, Florida, from 1958 to 1962. A reliable communication from an established ostetrician in Miami in March, 1973 informed me that "...nothing has changed in this field since you left here over ten years ago." The common practices of weight control and dietary salt restriction seem eternal.

Since it is now clear that the sudden, rapid weight gain observed in patients with severe MTLP is a result of malnutrition with a falling serum albumin concentration, hemoconcentration, a falling blood volume with increasing interstitial fluid, we no longer need to blindly "control weight" with starvation type diets. However, fear of the unknown drives the most rational and "scientific" people to irrational actions; millions of pregnant women in Western European medical culture still suffer from iatrogenic starvation diets in the vague hope that caloric and salt restriction will in some way protect them and their unborn from the "ancient enigma of obstetrics," eclampsia.

Iatrogenic starvation in human pregnancy has a long and ignoble history in the United States: its traditions run strong and deep in one of our oldest and most respectable journals of obstetrics, the American Journal of Obstetrics and Gynecology. In its second volume published in 1921 we find this account by Rucker:

"On August 2nd, two weeks after her first visit, her blood pressure was 120/80, the urine was free from albumin and sugar. On August 17 her weight had increased 6 pounds and her legs were swollen up to her knees. She had no headache. Blood pressure was 180/90. Urine was free from albumin and sugar. She was placed upon a bread and water diet." (emphasis added)

"A week later, August 24, in spite of her rigid diet, she had gained 8 3/4 pounds more. (emphasis added) Her blood pressure was 205/110 and she was having pains in the back of her head and was seeing specks before her eyes. The urine showed a trace of albumin. No casts were found."(7)

Subsequently this poor woman had 11 convulsions. It is now clear that a "bread and water diet" is not effective prophylaxis for MTLP!

In the very first volume of The American Journal of Obstetrics and Gynecology published 53 years ago [as of1974], Ehrenfest reviewed "Recent Literature on Eclampsia," and found that venesection was still in common use for this dread disease: "For the purpose of reducing the blood pressure and of eliminating toxins...."

He reported another then widespread approach: "Diuretics should be accompanied by a total or partial restriction of salt. No meat shall be allowed." (emphasis added) Ehrenfest also noted the beginning of a scientific rejection of blood-letting in the management of eclampsia: "Cragin says: Eclampsia patients after convulsions resemble so closely patients in shock, that venesection seems illogical. They seem to need all the blood they have and more too."(8)

Here was the obvious clinical recognition of the hypovolemic shock which so commonly causes maternal and fetal deaths in severe metabolic toxemia of late pregnancy.(9) The illogical use of salt diuretics in this disease may be viewed now as a "modern" form of blood-letting in which electrolytes and water of the blood are forced out of the patient's body via her kidneys, a kind of cell-free venesection!

In April, 1969, I presented a paper to an international meeting on "toxemia of pregnancy" in Basel, Switzerland, by invitation of Dr. E.T. Ripperman, Secretary of the Organization Gestose.(10) Here I learned these interesting facts:

1. Eclampsia has virtually disappeared from Switzerland; there had been no maternal death from this disease in Basel for almost two decades.
   
   
2. Some Swiss OB/GYN professors were still teaching that the pregnant woman must avoid red meat as prophylaxis against eclampsia; for the Swiss this prescription seems to be working.
   
   
3. The incidence of low birth weight babies born in the University Hospital, Basel, in the year 1967, from some 3,000 deliveries was 3.0%.

It soon became apparent here from my discussions with many European OB/GYN authorities that the general nutritional status of the peoples of Central Europe was exceptionally good, and that this adequate nutrition was the basic cause for the elimination of severe MTLP and for the relatively low incidence of low birth weight infants.

My own paper presented in Basel was received with the utmost skepticism: the European obstetricians almost to the man responded: "Surely there is no severe malnutrition in rich America." Surely? The incidence of low birth weight in our nation has risen from 7.0% in 1950 to 10.0% now [1974] with much higher figures for all our poverty areas; MTLP continues to cause maternal-fetal and newborn morbidity and mortality. Iatrogenic starvation during human pregnancy is still widely practiced throughout our nation today because none of our medical or "public health" institutions have taken concrete actions to stop it.

A review of the unbound issues of The American Journal of Obstetrics and Gynecology reveals that for most of the 1950's and 1960's amphetamines and other "diet pills" were widely advertised for "weight control" in human pregnancy. Salt diuretics, long recognized to be lethal to the severely toxemic patient and to her fetus, were promoted by this journal form 1958 to 1972. Professor Leon Chesley finally recognized their harmful effects on the maternal plasma volume.(11) The advertisements for these water pills were then stopped but not their widespread use.

Today in 1973 the problems of rising prices for essential foods like lean meats, chicken, eggs, vegetables and fruits, and the continuing poverty and economic depression in many areas of our nation can not be solved by the nation's physicians. However, do not humane physicians today have a special and moral responsibility to stop the blind errors of iatrogenic starvation in human pregnancy? Do not obstetricians, especially, in charge of human antenatal care in public clinics and private offices, have a responsibility to their pregnant patients to give them scientific nutrition information? The protective effects of applied, scientific nutrition in human antenatal care have recently been dramatically documented by Mrs. Agnes Higgins of the Montreal Diet Dispensary.(12) The rationale for blind weight control to any "magic number" of pounds in human pregnancy has been completely destroyed.(13) What then must the obstetricians of our nation do? What actions must they take to insure maternal-fetal and newborn health for each woman who wants to produce a normal, full term child and remain in good health herself?

1. Recognize the complications of human pregnancy caused by malnutrition.(14)
   
   
2. Teach each pregnant woman as a routine part of modern, scientific prenatal care, the basic principles of applied scientific nutrition.
   
   
3. Insure that she actually eats an adequate, balanced diet all through gestation.
   
   
4. Encourage her to salt her food "to taste." (with rare exception)
   
   
5. Stop "weight control" to any number of pounds. (when nutrition is adequate and balanced, the weight gain takes care of itself with an average gain in healthy pregnancy of about 35 pounds)
   
   
6. Protect each pregnant woman and her unborn from all harmful drugs, especially salt diuretics and appetite depressants.
   
   
7. On the postpartum wards educate all pregnant patients who have suffered nutritional complications during pregnancy--so that those complications will not recur in subsequent pregnancies.(15)
   
   
8. Stop iatrogenic starvation in human pregnancy.

These measures will begin to open a new era in preventive obstetrics in our nation and dramatically reduce the numbers of low birth weight and brain-damaged and mentally retarded children now being born.

There is more information related to IUGR babies following these references

REFERENCES

1. Hytten, F.E. and Leitch, I. The Physiology of Human Pregnancy. 2nd edition, Oxford, Blackwell Scientific Publications, 1970.
   
   
2. Prochownick, L. "Ein Versuch zum Ersatz der Kunstlichen Fruhgeburt" (An attempt towards the replacement of induced premature birth. Zbl. Gynak. 30:577, 1889.
   
   
3. Williams, Sue Rodwell. Nutrition and Diet Therapy, 2nd Edition. St. Louis, Mosby, 1973, Chapter 17.
   
   
4. Brewer, T.H. "Human Pregnancy Nutrition: an examination of traditional assumptions" Aust. N.Z. J. Obstet. Gynaecol. 10:87, 1970.
   
   
5. Pitkin, Roy M., Kaminetzky, Harold A., Newton, Michael, and Pritchard, Jack A. "Maternal nutrition: a selective review of clinical topics" Obstet. Gynecol. 40:773-785, 1972.
   
   
6. Brewer, T.H. "Human maternal-fetal nutrition". Obstet. Gynecol. 40:868-870, 1972.
   
   
7. Rucker, M. Pierce. "The Behavior of the uterus in eclampsia" Amer. J. Obstet. Gynecol. 2:179-183, 1921.
   
   
8. Ehrenfest, Hugo. "Collective review: recent literature on eclampsia". Amer. J. Obstet. Gynecol. 1:214-218, 1920.
   
   
9. Brewer, T.H. "Limitations of diuretic therapy in the management of severe toxemia of pregnancy: the significance of hypoalbuminemia" Amer. J. Obstet. Gynecol. 83:1352, 1962.
   
   
10. Brewer, T.H. "Metabolic toxemia of late pregnancy: a disease entity" Gynaecologia 167: 1-8, 1969. (Basel)
    
    
11. Chesley, Leon C. "Plasma and red cell volumes during pregnancy" Amer. J. Obstet. Gynecol. 112:440-450, 1972.
    
    
12. Primrose, T. and Higgins, A. "A study in human antepartum nutrition" J. Reproduct. Med. 7:257-264, 1971.
    
    
13. Pomerance, J. "Weight gain in pregnancy: how much is enough?" Clin. Pediat. 11:554-556, 1972.
    
    
14. Brewer, T. "Metabolic toxemia: the mysterious affliction." J. Applied Nutrition 24:56-63, 1972.
    
    
15. Brewer, T.H. "A case of recurrant abruptio placentae." Delaware Med. J. 41:325-331, 1969.

To summarize, here are some suggestions for treating IUGR:

1) Print out the weekly record on this page and post it on your refrigerator and make sure that there is a check mark in every box by the end of the day. That is the minimum intake needed. The next suggestions are for adding on top of that baseline.

See here for a weekly record chart that you can print and post on your refrigerator

2) Eat something with protein in it every hour of the day that you are awake, setting an egg timer or your watch or cell phone to go off every hour during the day, so that you do not skip one of these snacks. Some suggestions for these snacks include a handful of nuts, or cheese cubes, or an egg, or a cup of yogurt, or some trail mix, or a glass of milk. Keep a protein snack by your bedside for eating/drinking when you wake up during the night (suggestions: nut butter sandwich, cup of milk, cup of kifer). Try to increase the daily intake to 150-200 grams of protein (singleton pregnancy).

Also, for three days, eat 17 eggs a day and 2 quarts of milk a day.

3) Increase the number of nutritious calories eaten each day to 3,000-4,000 calories (singleton pregnancy). Avoid using junk food or refined carbohydrates to help with this increase.

One way to help your needed increase of calories is to start drinking a form of milk with a higher fat content--like switching from skim to 2%, or from 2% to whole, or whatever increase you can tolerate (like a mixture of 1/2 2% milk and 1/2 whole milk).

4) Make sure that you add salt to every serving of food that you eat. The Brewer Diet is actually a triad of salt PLUS calories PLUS protein, so an effort to expand the blood volume needs to include an increase of all three factors.

See here for more information about the benefits of salt in pregnancy

5) Add 500 mg. of choline to the daily supplements.

See here for more information about the above four suggestions

6) Evaluate your lifestyle and see if you can cut down on some kinds of physical activity, or live or work in a cooler environment, or cut out some stress-producing factors. All of these factors can add to your losses of salt, fluids, and calories. See this page for more ideas about this process (scroll to halfway down the page for the beginning of the suggestions)....

See here for suggestions for finding an optimal fit between your pregnancy and your lifestyle and your nutritional needs

7) Make sure that you avoid all herbs which have diuretic properties. Check the list of ingredients of all supplements and herbal teas that you use, to make sure that they do not contain any of the herbs listed on the page in the following link. My only exception to that would be Floradix, unless the use of all of the above suggestions has no effect, in which case I would suggest eliminating Floradix as well IF it includes one of the herbs listed here....

See here for more information on the hazards of herbal diuretics in pregnancy

8) You can also see this page for more suggestions for dealing with a rising BP (it includes some herbal suggestions)......

See the beginning of this page for some herbs to take alongside the added protein snacks

9) Take care to drink only fluids that have some kind of nutritious content. You can see more about that on this page....

See here for information about which kinds of fluids are optimal for treating the pre-eclampsia syndrome

10) If you have protein in your urine, make sure that the protein is not from a discharge from the vagina, or from a bladder or kidney infection. Sometimes at the end of pregnancy, as everything ripens, there is more discharge from the vagina, or if there's a yeast infection, some protein from the vagina can show up in the urine. To decrease the chances of protein from the vagina showing up in the urine, you can ask your midwife to help you do a "clean catch" of your urine sample. You can also ask your midwife to send your urine to a lab to be tested for other factors which may indicate a bladder or kidney infection.

11) Ask your midwife to test your hematocrit and hemoglobin. If it is stable or rising, then there's a good possibility that you are in an early PE process. For more information about that, and what to do for that, you can see the following link....

See here for Anne Frye's suggestions for testing and treatment of the pre-eclampsia syndrome

The following is from a chapter reprinted by permission from 21st Century Obstetrics Now! (David Stewart, PhD, and Lee Stewart, CCE, Editors), National Association of Parents & Professionals for Safe Alternatives in Childbirth, 1977. (p. 387)

"Why Women Must Meet the Nutritional Stress of Pregnancy" (p.387)

See here for the entire chapter that these charts were taken from

TABLE 4
RELATIONSHIP BETWEEN PRENATAL NUTRITION
AND BIRTH WEIGHT

Nutritional Status of Gravid Women	# of Women	% Low Birth Weight	Significance Level of Difference with Fairly Nourished Group
GOOD	63	3.2	p<.005
FAIR	272	11.0	- - -
POOR	28	33.0	p<.005

TABLE 5
RELATIONSHIP OF BIRTH WEIGHT
TO PRENATAL NUTRITION

Prenatal Diet	Good or Excellent	Fair	Poor or Very Poor
Number of Infants	31	149	36
Average Birth Weight	8lb,8oz (3856 g)	7lb,7oz (3374 g)	5lb,13oz (2637 g)

TABLE 6
EFFECT OF SUPPLEMENTATION ON
DECREASING LOW BIRTH WEIGHT INCIDENCE

	Amount of Caloric Supplementation During Pregnancy Less Than 5,000 5,000 to 19,999 At Least 20,000 Calories Number of Women 82 89 117 % Low Birth Weight 13.4 7.1 3.5

TABLE 7
LOW BIRTH WEIGHT INCIDENCE
AND DURATION OF PARTICIPATION

	Weeks of Nutrition Counseling Live Births Low Birth Weight Infants % Low Birth Weight 1-12 519 51 9.83 13-20 499 39 7.82 At least 21 713 29 4.07 All cases 1,731 119 6.87

FIGURE 1. Effect of nutrition education and food supplementation on birth weight for mother of 11.

	Child Nutrition Education or Supplementation Approximate Birth Weight First--Female None 2,700 grams (6 pounds) Second--Male None 2,500 grams (5 lbs 8 oz) Third--Male None 1,800 grams (4 pounds) Fourth--Female None 2,300 grams (5 lbs 1 oz) Fifth--Female None 2,100 grams (4 lbs 10 oz) Sixth--Male None 2,800 grams (6 lbs 3 oz) Seventh--Male None 2,300 grams (5 lbs 1 oz) Eighth--Male None 1,800 grams (3 lbs 15 oz) Ninth--Female Both 3,200 grams (7 lbs 1 oz) Tenth--Male Both 3,800 grams (8 lbs 6 oz) Eleventh--Female Both 3,400 grams (7 lbs 8 oz)

TABLE 8
INFLUENCE OF NUTRITION EDUCATION
IN LOWERING RISK OF LOW BIRTH WEIGHT

	# of Women	% Low Birth Weight
Infants born to primigravidas Receiving Nutrition Education	321	2.8
Infants born to other primigravidas Attending same County Clinic	1,237	13.7

TABLE 9
INFLUENCE OF NUTRITION
ON SURVIVAL AND WEIGHT AT BIRTH

	Calories or Nutrient (g) Optimum Requirements (As stated by the Authors) Approximate Stillbirths Daily Intake Low Birth Weight Infants by Group Normal- Weight Infants Calories 2,500 1,644 1,710 1,946 Carbohydrates 350 207 217 217 Fat 80 61.4 64.9 80.4 Protein 90 52.4 54.5 72.1 High-Quality Protein 50 27.4 29.9 45.9 Calcium 1.5 0.7 0.8 1.2 Phosphorus 2.0 0.9 0.9 1.4 Iron (mg) 15.0 9.0 9.0 11.0

TABLE 10
ASSOCIATION OF BIRTH WEIGHT
WITH VARIOUS TESTS AND MEASUREMENTS

Examination	Mean Difference Between the Higher Birth Weight Twins and the Lower Birth Weight Twins	Significance Level
Vocabulary Test	2.50	ns
I.Q.	6.75	p<.05
Height	4.34 cm (1.7 in.)	p<.01
Head Circumference	1.34 cm (0.5 in)	p<.001
Weight	3.95 kg (7 lb. 15 oz.)	p<.001

TABLE 11
ASSOCIATION OF BIRTH WEIGHT WITH I.Q.
AND MEASUREMENTS AMONG MONOZYGOTIC TWINS

	Examination Mean Difference Between the Higher Birth Weight Twins and the Lower Birth Weight Twins Significance Level I.Q. 6.56 p<.05 Height 5.89 cm (2.3 in.) p<.001 Head Circumference 1.67 cm (0.7 in.) p<.01 Weight 4.81 kg (9 lb. 11 oz.) p<.001

TABLE 12
ASSOCIATION BETWEEN BIRTH WEIGHT
AND RISK OF HANDICAP (514 Cases)

	Birth Weight Degree Moderate or Severe of Mild Handicap Little or None 1250 grams (2 lb, 12 oz) 64% (23) 17% (6) 19% (7) 1251-1500 grams (2 lb, 12 oz to 3 lb, 5 oz) 34% (16) 21% (10) 45% (21) 1501-1750 grams (3 lb, 5 oz to 3 lb, 13.75 oz) 19% (5) 23% (6) 58% (15) 1751-2000 grams (3 lb, 13.75 oz to 4 lb, 6.5 oz) 12% (8) 30% (20) 58% (39) 2001-2250 grams (4 lb, 6.5 oz to 4 lb, 15.5 oz) 4% (2) 23% (13) 74% (42) 2251-2500 grams (4 lb, 15.5 oz to 5 lb, 8 oz) 3% (3) 16% (19) 81% (94) 2501 grams (5 lb, 8 oz) and over 1% (2) 12% (20) 87% (143)

TABLE 13
INFLUENCE OF BIRTH WEIGHT
ON DISTRIBUTION OF I.Q. SCORES
BY SOCIOECONOMIC STATUS

	Socio- economic Class I.Q. Centile Birth 2000 and Under Weight (g) 2001-2500 Middle Under 25th 25th to 75th Over 75th Total 55% (29) 36% (19) 9% (5) 100% (53) 39% (26) 44% (29) 17% (11) 100% (66) Working Under 25th 25th to 75th Over 75th Total 64% (29) 25% (11) 11% (5) 100% (45) 36% (28) 47% (37) 18% (14) 100% (79) Lower Under 25th 25th to 75th Over 75th Total 52% (14) 44% (12) 4% (1) 100% (27) 48% (15) 45% (14) 6% (2) 100% (31)

TABLE 14
RELATIONSHIP BETWEEN BIRTH WEIGHT
AND CHILDHOOD BEHAVIOR
BY SOCIAL CLASS

	Socioeconomic Class Total # of Children % Stable % Unsettled % Maladjusted Birth Middle Working Lower Weight 42 36 28 Under 69 47 36 2001 24 19 36 grams 7 33 29 Birth Middle Working Lower Weight 71 54 29 Over 79 70 45 2500 15 20 41 grams 6 9 14

TABLE 15
RELATIONSHIP BETWEEN I.Q. AND BIRTH WEIGHT
AMONG 51 RETARDATES AND MATCHED CONTROLS

	Average I.Q. Average Birth Weight Average Birth Weight Exclusive of Low Birth Weight and/or Premature Children MALES Retarded Children Control Group 70 121 3020 grams (6 lb, 10.63 oz) (N = 25) .........(p<.002) 3750 grams (8 lb, 4.37 oz) (N = 25) 3300 grams (7 lb, 4.5 oz) (N = 20) .........(p<.002) 3830 grams (8 lb, 7.25 oz) (N = 24) FEMALES Retarded Children Control Group 67 124 3020 grams (6 lb, 10.63 oz) (N = 25) .........(p<.002) 3750 grams (8 lb, 4.37 oz) (N = 25) 3080 grams (6 lb, 12.75 oz) (N = 20) .........(p<.002) 3440 grams (7 lb, 9.37 oz) (N = 25)

TABLE 16
ASSOCIATION BETWEEN BIRTH WEIGHT
AND DEVELOPMENT OF RDS

Birth Weight	Total # of Children	Incidence of RDS	Incidence of Severe RDS
1250 grams or less	12	75%	42.0%
Over 1250 grams	28	32%	3.5%

TABLE 17
RISK OF MENTAL RETARDATION
AMONG CHILDREN WITH RDS

	# of Children	Incidence of Mental Retardation Among Children with RDS
Severe RDS	6	67%
Less Severe RDS	12	8%

TABLE 19
RELATIONSHIP OF PRENATAL NUTRITION
AND BIRTH WEIGHT TO NEONATAL HEALTH

	Pediatric Superior Ratings Good of Fair Infants Poor Number of infants 23 84 76 33 Average Birth Weight 8lb, 2oz (3685g) 7lb,12oz (3515g) 7lb, 2oz (3232g) 5lb, 15oz (2693g) Women on Good or excellent Prenatal Diet 56% 19% 1% 3% Women on Poor or Very Poor Prenatal Diet 9% 2% 12% 79%

TABLE 20
INFLUENCE OF DIET IN REDUCING RISK OF
MISCARRIAGE, STILLBIRTH, AND PREMATURE BIRTH

	Type of Diet # of Women % Miscarriages % Stillbirths % Premature Good 170 1.2 0.6 3.0 Supplemented 90 0.0 0.0 2.2 Poor 120 6.0 3.4 8.0

TABLE 21
PRENATAL DIET BY
CONDITION OF BABY AT AGE TWO WEEKS

Prenatal Diet Group	Good	Condition Fair	of Baby Poor	Bad
Good	72.2%	23.8%	1.2%	3.0%
Supplemented	90.5%	9.5%	0.0%	0.0%
Poor	62.3%	23.7%	5.3%	8.7%

TABLE 22
EFFECT OF NUTRITION ON REDUCING MODERATELY LOW BIRTH WEIGHT,
STILLBIRTH, AND INFANT MORTALITY

	Study Group Control Group Signif. Level of Difference Total Number 750   750     Births Under 5 lb (2268g) 0 (0%) 37 (4.9%) p<10-8 Stillbirths (rate) 0 0 20 26.7 p<10-6 Infant Deaths (rate) 3 4.0 41 54.6 p<10-7

TABLE 23
MORTALITY BY DEGREE
OF CALORIC SUPPLEMENTATION

	# of Women First 6 Months More Than 6 But Less Than 9 Months Over 9 Months But Less Than 1 Year High Supple- mentation 199 3.0% 0.9% 0.0% Low Supple- mentation 454 5.3% 1.2% 0.6%

21st Century Obstetrics Now! Vol. 2 available here

Perinatal Support Services: pregnancydiet@mindspring.com