After the shock / excitement / stunned silent reaction to the news you’re expecting multiple babies has subsided, you may turn to practical matters. For example, how will you nourish yourself and your babies throughout your pregnancy? 

Generally the basic guidelines for a multiple pregnancy are similar to those for singletons, with some exceptions and additional requirements. Multiple pregnancies are associated with an increased risk of low birthweights because of prematurity and growth restriction.  The goods news is there is increasing evidence that good maternal nutrition in multiple pregnancies is linked with improved outcomes. Babies who are well nourished in utero have higher birthweights and are less likely to be born early - obviously this depends on what and how you eat. 

You may be told to eat more, but this doesn’t mean eat as much as you like or whatever you like.  Interestingly recent scientific studies are showing that both low and high birth weight babies have an increased risk of obesity in childhood and adulthood, hence you want to maintain good growth but not over-feed your babies or feed them the wrong things. 

The nutrient requirements for twin and multiple pregnancies are significantly increased both for pregnant and breastfeeding women. There are increased needs for all nutrients, but especially energy, protein, iron, folate, calcium, vitamin D and the essential fatty acids.

Weight gain:
Optimal weight gain will vary depending on your height, build and whether you began your pregnancy overweight, under weight at an ‘ideal’ weight.  If your pre-pregnancy BMI (Body Mass Index) was in the normal range (20-25kgm²) the evidence suggests that weight gain in twin pregnancies should be 16-20kg and at least 22kg in triplet pregnancies.  If you start underweight then your weight gain will need to be higher and if you were overweight then weight gain should be lower.  It’s also important to gain weight in the first trimester.

Energy: 
Additional energy is required in multiple pregnancies as you need to lay down more fat to cope with the extra demands on your body now and when you start breastfeeding, plus there will be an added requirement for each foetus and placenta. 

A major difference from singleton pregnancies is that it’s important to start laying down energy reserves in the first trimester.  Just because you need extra energy this doesn’t mean you should resort to bags of chippies and chocolate – it’s still important to have a healthy balanced diet.  The proportion of calories you should get from protein, fat and carbohydrates should remain the same no matter how many babies you are carrying, but the total energy required increases with each baby.

It’s important that not too much of your energy comes from simple sugars, for example those found in sweets, biscuits, confectionery, soft drinks or added to hot drinks, breacereals and desserts, because there is an increased risk of gestational diabetes when carrying multiples.  Eat three meals a day plus two to three substantial snacks (i.e. breakfast, morning tea, lunch, afternoon tea, dinner, bedtime snack).  It’s important to have well spaced meals throughout the day to maintain even blood sugar levels. Aim to increase your consumption of foods with a low Glycemic Index (GI) and always remember to space out your consumption of carbohydrate rich foods.

Protein:
Another dietary requirement that needs to be increased if you're expecting more than one baby is protein intake, which has several important functions. Proteins serve as the building blocks of body tissue and since you’re building two or more babies it’s vitally important.  There are no firm guidelines on additional protein requirements but suggestions are for a total of 80-100 g protein per day (and some recommend even more).  The easiest thing to do is have an additional serve of protein rich food (e.g. meat, eggs, dairy products or legumes) each day over that recommended for a singleton pregnancy.

Folate:
Folic acid is important for brain growth and neurological development and is essential in preventing neural tube defects such as spina bifida.  As you’re developing two little minds it is doubly important, especially through the first trimester (though for most of it you may not know you’re carrying twins).  The level of folate in supplements is usually 400μg (micrograms) per day and in most cases this is thought to be sufficient when added together with dietary sources.  There is limited data on requirements for multiple pregnancies but in general it’s thought that when pregnant with twins or more than two babies 800-1,000 μg per day is better.

Iron:
The increase in blood volume is greater in multiple pregnancies and the demands of more than one foetus increase requirements for iron.  It’s during the second trimester that iron is particularly important as your blood volume carrying multiples can increase by 100% or more over your non-pregnant levels.  It’s in the third trimester that iron stores are laid down in the babies.  Data indicates if you’re pregnant with twins you need 1.8 times more iron than those with a singleton pregnancy.  Make sure you include red meat and chicken in the protein rich foods you eat.  Supplementation is often required but not always if you maintain a good diet.

Calcium:
There is some debate over calcium needs for pregnant women as it appears during pregnancy calcium absorption increases.  Since you’re also developing two or more sets of bones and teeth an increased calcium intake is wise, especially in the last trimester.  You should aim for a total intake of 1,200μg per day and that equates to four serves of dairy or dairy equivalents per day (an extra serve of dairy per baby over non-pregnant levels).  Dairy foods are good as they also provide important protein in the diet. Examples include yoghurt, cheese, ice-cream and milk.

Supplements:
Just because there are increased nutritional needs it doesn’t mean you should double the dose of vitamin/mineral supplements as there can be some potentially harmful effects.  Ideally the extra vitamin and mineral needs should come from a combination of foods, as food provides the energy required that is not present in supplements.  Any intake of pills beyond standard pregnancy supplements should only be done in consultation with a medical professional or nutrition specialist.

Food safety:
Because multiple pregnancies are classed as ‘high risk’ it’s especially important to be aware of food safety and hygiene issues. For details Refer to the Ministry of Health’s booklet called ‘Eating for Healthy Pregnant Women’ www.moh.govt.nz.

Thank you to New Zealand Multiple Birth Association Incorporated for their assistance with this article. This voluntary group has 21 local Multiple Birth clubs supporting over 1400 families throughout the country. These clubs offer fantastic information and support for families expecting twins or more. They can be contacted on 0800 489467, or email info@multiples.org.nz  or you can visit their website www.multiples.org.nz

References:

Books:
When You're Expecting Twins, Triplets, or Quads: Proven Guidelines for a Healthy Multiple Pregnancy by Barbara Luke. Resource Publications Incorporated (HarperCollins); June 2004

Everything You Need to Know to Have a Healthy Twin Pregnancy by Gila Leiter, M.D., with Rachel Kranz. Bantam Dell Publishing (Random House); November 2000.

Expecting Twins, Triplets, and More: A Doctor's Guide to a Healthy and Happy Multiple Pregnancy by Rachel Franklin. Martin's Press; March 2005.

Twins: A Practical Guide to Parenting Multiples from Conception to Two Years Old by Katrina Bowman, Louise Ryan, et al. Allen & Unwin Pty., Limited; September 2005.

Papers:
Brown JE, Schloesser PT. 1990. Prepregnancy weight status, prenatal weight gain, and the outcome of term twin gestations. American Journal of Obstetrics and Gynecology 162(1): 182-186.

Goodnight W, Newman R 2009. Optimal Nutrition for Improved Twin Pregnancy Outcome. Obstetrics & Gynecology 114(5): 1121-1134.

Luke B. 2004. Improving multiple pregnancy outcomes with nutritional interventions. Clinical Obstetrics and Gynecology 47(1): 146-162.

Luke B, Hediger ML, Nugent C, et al. 2003. Body mass index . specific weight gains associated with optimal birth weights in twin pregnancies. Journal of Reproductive Medicine 48(4): 217-224.

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