Breastfeeding: Maternal diet and lifestyle

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Breastfeeding Maternal diet and lifestyle
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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?

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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

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How is milk made?
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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

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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

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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

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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

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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.

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• 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

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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

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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,..

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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

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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

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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

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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?

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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

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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

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Calcium

• Calcium intake has little impact on calcium
  content of breastmilk
• ? Is there an impact on maternal calcium status
  and bone density

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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

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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 - 700 - 800 - 1000
Iodine 95 160 209
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DRI
nutrient Female 14-18 19-50 Pregnancy 14-18 19-50 Lactation 14-18 19-50
A 700 750 770 1200 1300
C 75 80 85 115 120
E 15 15 19 19
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DRI
nutrient Female 14-18 19-50 Pregnancy 14-18 19-50 Lactation 14-18 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

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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

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• Cultural/religious customs
• Vegan/vegetarian diets
• dieting

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Frequently seen advise to breastfeeding women

• Eat to hunger
• Drink to thirst
• Dont worry

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Modification of infant health through maternal
diet

• DHA
• Allergy
• Colic

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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.

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AAP Breast milk and allergy

• 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.

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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

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David Hill et al

• N107 infants lt6weeks of age with colic defined by
  elevated Cry/Fuss Score.
• Study Group 53, 680 minutes/48 hours
• Control 54, 631 minutes/48 hours

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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

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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 gt360 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 gt 360 min/48 hours

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• Authors Conclusion Exclusion of allergenic foods
  from maternal diet was associated with a
  reduction in distressed behavior among breast fed
  infants lt6 weeks of age.

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What advise?

• Diet restrictions
• Diet supplements
• Allergens
• other

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Drugs and Environmental Contaminants
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Drugs and Human Milk

• Maternal considerations
• Drug Characteristics
• Concentration in milk
• Volume of milk consumed
• Infant Characteristics

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Maternal considerations

• Route
• Dose
• Duration
• ? Treatment
• ? alternative

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Drug Characteristics

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

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Drug Characteristics

• Drugs transferred by simple diffusion, carrier
  mediated, active transfer, pinocytosis, reverse
  pinocytosis.
• Transfer and solubility gradient

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

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Infant Characteristics

• ? Absorption from infant gut
• ? Infant metabolism
• Can infant detoxify and excrete?
• Will amounts accumulate
• What doses/ levels are safe?

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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?

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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

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NAS Food and Nutrition board 1992

• Environmental contaminants
• Heavy metals e.g. mercury
• Organic chemicals e.g. pesticides
• DDT, PCBs

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Drug use and Pregnancy

• Drugs contraindicated
• Should be avoided if there are alternatives
• No known risk

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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.

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

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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)

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• 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

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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.

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Alcohol

• Compatible with breastfeeding but use
  caution/moderation.

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Caffeine

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

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Drugs and Lactation

• Thomas Hale Medications and Mothers 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

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What Advise would you give?

• Maternal diet and health?
• Diet modification for infants health?
• DHA, Vitamin Supplements, elimination diets

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What advice would you give?

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