1. Breastfeeding: Maternal diet and lifestyle

2. 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?

3. 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

4. How is milk made?

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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”

12. 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,…..

13. 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

14. 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

15. 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

16. 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?

17. Energy + 500 kcal above non lactating women
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

18. 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

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

20. 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

21. DRI Nutrient Female Pregnancy Lactation Protein g/d 38 50 Calcium mg/d60
Calcium mg/d
Phosphorus mg/d
Zinc mg/d
Iron mg/d
Copper ug/d
- 700
- 800
- 1000
Iodine 95
160
209

22. DRI nutrient Female Pregnancy Lactation A C E 700 750 770 1200 1300 75
Pregnancy
Lactation A
700 C 75 E 15

23. DRI nutrient Female Pregnancy Lactation Thiamin 1 1.1 1.4 1.4 1.4 1.4
Pregnancy
Lactation
Thiamin
riboflavin
niacin B6
folate
B12

24. 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

25. Cultural/religious customs
Vegan/vegetarian diets
dieting

26. Frequently seen advise to breastfeeding women
Eat to hunger
Drink to thirst
Don’t worry

27. Modification of infant health through maternal diet
DHA
Allergy
Colic

28. 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.

29. 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.

30. 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

31. 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

32. 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

33. Hill et al Study Group Control 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

34. 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.

35. What advise?
Diet restrictions
Diet supplements
Allergens
other

36. Drugs and Environmental Contaminants

37. Drugs and Human Milk Maternal considerations Drug Characteristics
Concentration in milk
Volume of milk consumed
Infant Characteristics

38. Maternal considerations
Route
Dose
Duration
? Treatment
? alternative

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

40. Drug Characteristics
Drugs transferred by: simple diffusion, carrier mediated, active transfer, pinocytosis, reverse pinocytosis.
Transfer and solubility gradient

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

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

43. 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?

44. AAP statement on Drugs and Human Milk
Pediatrics (3)
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

45. NAS Food and Nutrition board 1992
Environmental contaminants:
Heavy metals e.g. mercury
Organic chemicals e.g. pesticides
DDT, PCB’s

46. Drug use and Pregnancy Drugs contraindicated
Should be avoided if there are alternatives
No known risk

47. 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.

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

49. 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)

50. 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

51. 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.

52. Alcohol
Compatible with breastfeeding but use caution/moderation.

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

54. Drugs and Lactation
Thomas Hale Medications and Mother’s Milk 11th edition 2004 Pharmasoft Publishing L.P., Texas
Gerald G. Brigs et al Drugs in Pregnancy and Lactation 7th edition 2005 Lippincott Williams and Wilkins

55. What Advise would you give?
Maternal diet and health?
Diet modification for infants health?
DHA, Vitamin Supplements, elimination diets

56. 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?”