breastfeeding: maternal diet and lifestyle. maternal nutrient needs for successful lactation impact...

Breastfeeding: Maternal diet and lifestyle

Breastfeeding: Maternal diet and lifestyle

• Maternal nutrient needs for successful lactation

• Impact of maternal diet on milk composition

• Can infant health outcomes be influenced by manipulating the deit of lactating women?

Breastfeeding: Maternal diet and lifestyle

• Lifestyle issues– Supportive of

sustained lactation– Impacting milk

production and compostion

– Health and safety issues

• Drug exposure• Environment

contaminants• other

How is milk made?

Milk Synthesis

• Mammary gland contains stem cells and highly differentiated secretory alveolar cells at the terminal ducts. Stimulated by insulin and HGH synergized by prolactin, these cells are active in milk synthesis and secretion

Milk Synthesis and secretion

• Under neuroendocrine control that varies with timing and stage of lactation– Prolactin– Lactogens– Estrogen– Thyroxine– Growth hormone– ACTH– other

– Stimulus: infant suckling

Milk synthesis and sectretion

• Exocytosis (protein, lactose, Ca/Ph, citrate)

• Fat synthesis (TG synthesized in cytoplasm and smooth endoplasmic reticulum + precursors imported from maternal circulation): alveolar cells syntesize SCFA

• Secretion of ions and water

• Immunoglobins transferred from extracellular spaces

Milk synthesis

• Protein: vast majority of proteins present in human milk are specific to mammary secretions and not identified in any quantitiy elsewhere in nature:– Immunoglobins transferred from plasma in

early stages of lactation– De novo protein synthesis by mammary gland

Paracellular Pathway (5th process)

• The paracellular spaces between alveolar cells normally prevent transfer secondary to tight junctions. If these spaces become “leaky” plasma constituents may pass directly into the milk.

• Association of maternal diet with milk composition?– Volume– Nutrient composition

• Can diet alter nutrient composition of

maternal milk?

* in general milk composition maintained to meet infant needs.

* water soluble vitamins

* fat/fatty acids

Science and Lactation: Frank Hytten

• “ In general, it is probable that the breast has a high priority for nutrients and that moderate maternal undernutrition will have little effect on milk production. But severe malnutrition, which rarely exists without associated ill-health and other adverse circumstances, may reduce milk yield”

Diet, milk production, and milk composition

• There is a great variation in milk composition during a feed, from feed to feed, and even between breasts.

• The impact of dietary variation and milk composition is unclear. Overall milk composition remains relatively unaffected by diet variations although there are reports to the contrary:– DHA and ARA supplementation, vegan diet, drugs

and environmental contaminants,…..

Influence of diet on milk composition

• Protein-energy malnutrition impacts milk volume. Composition remains relatively unaffected

• Water soluble vitamins move readily from serum to milk thus dietary fluctuations are more apparent– B12 vegan, case report of beri-beri…..

• Fat soluble vitamin content not improved with supplementation

• Fatty acid composition (DHA and ARA) altered by maternal diet and supplementation

Breast milk composition and Diet

• DHA levels of breastmilk vary with diet. Increased amounts of DHA have been found in the breaskmilk of mothers consuming fish or fish oil, and with suppleemntation.

• Water soluble vitamins may vary with diet. Diets inadequate in B12 or thiamin have been associated with case reports of deficiency in infants. High intakes of Vitamin C, however, does not apear to change the content of breastmilk.

• Supplementation of fat soluble vitamins do not appear to alter the content of breastmilk

• Iron supplementation does not appear to alter the iron content of breastmilk

Questions regarding Breast milk composition and Diet

Maternal deficiencies and infant health

Infant health vs maternal health

Treatment of specific conditions or “supermilk” through dietary modification

Nutrient Needs

• Increased Needs?• Replace maternal

losses to milk?• Increased energy

needs---- increase in specific vitamins (ie B vitamins)

• Association of maternal diet with milk composition?

Energy

• Estimate need to produce 850 ml/day

• 600 kcal/d• 80% efficiency• 750 kcal/day• Fat stores of

pregnancy may provide 1/3

• + 500 kcal above non lactating women

Energy

• Does a breastfeeding woman need to consume more energy to sustain lactation?– Energy deficits may not impact milk volume– ? Estimating energy cost– Variety of ways to meet energy needs

• Increased consumption• Decreased expenditure• Mobilization of stores

Calcium

• Calcium intake has little impact on calcium content of breastmilk

• ? Is there an impact on maternal calcium status and bone density

Calcium

• Calcium is mobilized from bone to maintain milk content during lactation

• Phenomena of bone loss and recovery during lactation and after weaning has been documented by several researches (Cross, Kalkwark, Specker) and may represent normal physiology

• ? Consequences of inadequate intake on long term maternal bone health

DRI

Nutrient Female Pregnancy Lactation

Protein g/d 38 50 60

Calcium mg/d

1000 - 1300 1000 - 1300 1000 - 1300

Phosphorus mg/d

1055 - 580 1055 - 580 1055 - 580

Zinc mg/d 6.8 - 7.3 9.5 - 10.5 10.4 - 10.9

Iron mg/d 7.9 - 8.1 22 - 23 6.5 - 7

Copper ug/d 685 - 700 785 - 800 985 - 1000

Iodine 95 160 209

DRI

nutrient Female14-18 19-50

Pregnancy14-18 19-50

Lactation14-18 19-50

A 700 700 750 770 1200 1300

C 65 75 80 85 115 120

E 15 15 15 15 19 19

DRI

nutrient Female14-18 19-50

Pregnancy14-18 19-50

Lactation14-18 19-50

Thiamin 1 1.1 1.4 1.4 1.4 1.4

riboflavin 1 1.1 1.4 1.4 1.6 1.6

niacin 14 14 18 18 17 17

B6 1.2 1.3 1.9 1.9 2 2

folate 400 400 600 600 500 500

B12 1.8 2.4 2.6 2.6 2.8 2.8

NAS Food and Nutrition Board 1992

• Healthful diet based on DRI/RDA• Avoid or drastically reduce the use of potentially

harmful substances• Take enough fluids to keep from getting thirsty• At least 1800 kcal/d to maintain milk production• Limit intake of coffee, cola or other caffeine

sources to 2 servings or less per day• Avoid alcoholic beverages

• Cultural/religious customs

• Vegan/vegetarian diets

• dieting

Frequently seen advise to breastfeeding women

• Eat to hunger• Drink to thirst• Don’t worry

Modification of infant health through maternal diet

• DHA• Allergy• Colic

Allergies: Breastmilk• May be protective due to sIgA and

mucosal growth factors

• Maternal avoidance diets in lactation remain speculative. May be useful for some highly motivated families with attention to maternal nutrient adequacy.

• 1.Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Those breastfeeding infants who develop symptoms of food allergy may benefit from: – a.maternal restriction of cow's milk, egg, fish,

peanuts and tree nuts and if this is unsuccessful, – b.use of a hypoallergenic (extensively hydrolyzed

or if allergic symptoms persist, a free amino acid-based formula) as an alternative to breastfeeding.

AAP: Breast milk and allergy

Colic and maternal diet

• David Hill et al Effect of Low allergen Maternal Diet on Colic among breastfed Infants: A Randomized controlled Trial, Pediatrics Vol 116 #5 Nov 2005 709-15

David Hill et al

• N107 infants <6weeks of age with colic defined by elevated Cry/Fuss Score.

• Study Group: 53, 680 minutes/48 hours

• Control: 54, 631 minutes/48 hours

Hill et al

• Study: Low allergen. Maternal elimination of cows milk, peanuts, treenuts, wheat, soy, and fish.

• 47 completed

• Control: Diet as usual.• 43 completed

Hill et al

• Study Group– Reduction in cry score

by 25% (35 of 47)– 30/47 still had colic as

defined by cry/fuss scores >360 min/48 hours

• Control Group– Reduction of cry score

by 25% (16 of 43)– 31/43 still had colic as

defined by cry/fuss score > 360 min/48 hours

• Authors Conclusion: Exclusion of allergenic foods from maternal diet was associated with a reduction in distressed behavior among breast fed infants <6 weeks of age.

What advise?

• Diet restrictions• Diet supplements• Allergens• other

Weighing Risks and Benefits

Drugs and Environmental Contaminants

Drugs and Human Milk

• Maternal considerations

• Drug Characteristics

• Concentration in milk

• Volume of milk consumed

• Infant Characteristics

Maternal considerations

• Route

• Dose

• Duration

• ? Treatment

• ? alternative

Drug Characteristics

• Size of molecule• Solubility in lipids and water• Protein binding capability• Drug pH• Diffusion rates• Half life• Metabolites

Drug Characteristics

• Drugs transferred by: simple diffusion, carrier mediated, active transfer, pinocytosis, reverse pinocytosis.

• Transfer and solubility gradient

• Concentration in milk X amount milk consumed = potential dose infant exposed to

Infant Characteristics

• ? Absorption from infant gut

• ? Infant metabolism

• Can infant detoxify and excrete?

• Will amounts accumulate

• What doses/ levels are safe?

Infant

• Is this a drug normally given to an infant?– Amount, side-effects, safe dose and level

known.

• Is this a drug not usually given to infant?– More difficult question, is safety known, is

there any evidence or data to make a decision, is there fetal or animal data on safety?

AAP statement on Drugs and Human Milk

• Pediatrics 2001 108(3) 776-788• 7 tables

– 1) cytotoxic drugs that may interfere with infant metabolism– 2) drugs of abuse for which adverse effects on infants have been

reported– 3) radioactive drugs requiring temporary cessation of nursing– 4) drugs with unknown effects– 5) drugs with some associated effects that should be used with

caution– 6) medications compatible with nursing– 7) food and environmental agents that may have effects on

breastfeeding

NAS Food and Nutrition board 1992

• Environmental contaminants:– Heavy metals e.g. mercury– Organic chemicals e.g. pesticides

• DDT, PCB’s

Drug use and Pregnancy

• Drugs contraindicated

• Should be avoided if there are alternatives

• No known risk

AAP: Breastfeeding and Smoking

• 1994: Nicotine placed in Contraindicated secondary to decrease in milk production, decrease weight gain in infant, and increase in respiratory illness etc.

• ? Breastfeeding and smoking vs bottle feeding and smoking…..protection against respiratory illness

• 2001: In the interest of supporting breastfeeding, Nicotine was removed from the previous Table.

• Advise against smoking. Provide support for smoking cessation.

• Smoking: nicotine exposure, carbon monoxide, risk of 2nd hand smoke, burns

AAP: Drugs of abuse for which adverse effects have been reported• Amphetamine: irritability, poor sleeping pattern• Cocaine: cocaine intoxication, irritability,

vomiting, diarrhea, tremulousness, seizures• Heroin: tremors, restlessness, vomiting, poor

feeding• Marijuana: only one report in literature, no effect

mentioned, very long half life for metabolites (see animal studies)

• Marijuana: animal studies show structural changes in brain cells of newborns exposed to cannabis through maternal milk, impaired RNA/DNA formation. Infant would be exposed through milk and environment

AAP: Alcohol

• With large amounts, drowsiness, diaphoresis, deep sleep, weakness, decrease in linear growth, abnormal weight gain, maternal ingestion of 1g/kg daily decreases milk ejection reflex.

Alcohol

• Compatible with breastfeeding but use caution/moderation.

Caffeine

• Irritability, poor sleeping pattern, excreted slowly, no effect with moderate intake of caffienated beverages (2-3 cups per day)

• General advise, use moderation.

Drugs and Lactation

• Thomas Hale Medications and Mother’s Milk 11th edition 2004 Pharmasoft Publishing L.P., Texas http://www.iBreastfeeding.com

• Gerald G. Brigs et al Drugs in Pregnancy and Lactation 7th edition 2005 Lippincott Williams and Wilkins

What Advise would you give?

• Maternal diet and health?

• Diet modification for infants health?– DHA, Vitamin

Supplements, elimination diets

What advice would you give?

• Drugs/medications• Smoking• Caffiene• Alcohol• “ is there a list of foods I

shouldn’t eat?”• “is there a list of foods

that I should eat?”• “is it ok to be a

vegetarian?”• “are there foods that

make my baby gassy?”