2Breastfeeding: Maternal diet and lifestyle Maternal nutrient needs for successful lactationImpact of maternal diet on milk compositionCan infant health outcomes be influenced by manipulating the deit of lactating women?
3Breastfeeding: Maternal diet and lifestyle Lifestyle issuesSupportive of sustained lactationImpacting milk production and compostionHealth and safety issuesDrug exposureEnvironment contaminantsother
5Milk SynthesisMammary 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
6Milk Synthesis and secretion Under neuroendocrine control that varies with timing and stage of lactationProlactinLactogensEstrogenThyroxineGrowth hormoneACTHotherStimulus: infant suckling
7Milk 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 SCFASecretion of ions and waterImmunoglobins transferred from extracellular spaces
8Milk synthesisProtein: 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 lactationDe novo protein synthesis by mammary gland
9Paracellular 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.
10Association of maternal diet with milk composition? VolumeNutrient compositionCan diet alter nutrient composition ofmaternal milk?* in general milk composition maintained to meet infant needs.* water soluble vitamins* fat/fatty acids
11Science 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”
12Diet, 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,…..
13Influence of diet on milk composition Protein-energy malnutrition impacts milk volume. Composition remains relatively unaffectedWater soluble vitamins move readily from serum to milk thus dietary fluctuations are more apparentB12 vegan, case report of beri-beri…..Fat soluble vitamin content not improved with supplementationFatty acid composition (DHA and ARA) altered by maternal diet and supplementation
14Breast 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 breastmilkIron supplementation does not appear to alter the iron content of breastmilk
15Questions regarding Breast milk composition and Diet Maternal deficiencies and infant healthInfant health vs maternal healthTreatment of specific conditions or “supermilk” through dietary modification
16Nutrient 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?
17Energy + 500 kcal above non lactating women Estimate need to produce 850 ml/day600 kcal/d80% efficiency750 kcal/dayFat stores of pregnancy may provide 1/3+ 500 kcal above non lactating women
18EnergyDoes a breastfeeding woman need to consume more energy to sustain lactation?Energy deficits may not impact milk volume? Estimating energy costVariety of ways to meet energy needsIncreased consumptionDecreased expenditureMobilization of stores
19CalciumCalcium intake has little impact on calcium content of breastmilk? Is there an impact on maternal calcium status and bone density
20CalciumCalcium is mobilized from bone to maintain milk content during lactationPhenomena 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
24NAS Food and Nutrition Board 1992 Healthful diet based on DRI/RDAAvoid or drastically reduce the use of potentially harmful substancesTake enough fluids to keep from getting thirstyAt least 1800 kcal/d to maintain milk productionLimit intake of coffee, cola or other caffeine sources to 2 servings or less per dayAvoid alcoholic beverages
26Frequently seen advise to breastfeeding women Eat to hungerDrink to thirstDon’t worry
27Modification of infant health through maternal diet DHAAllergyColic
28Allergies: Breastmilk May be protective due to sIgA and mucosal growth factorsMaternal avoidance diets in lactation remain speculative. May be useful for some highly motivated families with attention to maternal nutrient adequacy.
29AAP: 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.
30Colic 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
31David Hill et alN107 infants <6weeks of age with colic defined by elevated Cry/Fuss Score.Study Group: 53, 680 minutes/48 hoursControl: 54, 631 minutes/48 hours
32Hill et alStudy: Low allergen. Maternal elimination of cows milk, peanuts, treenuts, wheat, soy, and fish.47 completedControl: Diet as usual.43 completed
33Hill 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 hoursControl GroupReduction of cry score by 25% (16 of 43)31/43 still had colic as defined by cry/fuss score > 360 min/48 hours
34Authors Conclusion: Exclusion of allergenic foods from maternal diet was associated with a reduction in distressed behavior among breast fed infants <6 weeks of age.
37Drugs and Human Milk Maternal considerations Drug Characteristics Concentration in milkVolume of milk consumedInfant Characteristics
38Maternal considerations RouteDoseDuration? Treatment? alternative
39Drug Characteristics Size of molecule Solubility in lipids and water Protein binding capabilityDrug pHDiffusion ratesHalf lifeMetabolites
40Drug CharacteristicsDrugs transferred by: simple diffusion, carrier mediated, active transfer, pinocytosis, reverse pinocytosis.Transfer and solubility gradient
41Concentration in milk X amount milk consumed = potential dose infant exposed to
42Infant Characteristics ? Absorption from infant gut? Infant metabolismCan infant detoxify and excrete?Will amounts accumulateWhat doses/ levels are safe?
43Infant 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?
44AAP statement on Drugs and Human Milk Pediatrics (3)7 tables1) cytotoxic drugs that may interfere with infant metabolism2) drugs of abuse for which adverse effects on infants have been reported3) radioactive drugs requiring temporary cessation of nursing4) drugs with unknown effects5) drugs with some associated effects that should be used with caution6) medications compatible with nursing7) food and environmental agents that may have effects on breastfeeding
45NAS Food and Nutrition board 1992 Environmental contaminants:Heavy metals e.g. mercuryOrganic chemicals e.g. pesticidesDDT, PCB’s
46Drug use and Pregnancy Drugs contraindicated Should be avoided if there are alternativesNo known risk
47AAP: 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 illness2001: In the interest of supporting breastfeeding, Nicotine was removed from the previous Table.Advise against smoking. Provide support for smoking cessation.
48Smoking: nicotine exposure, carbon monoxide, risk of 2nd hand smoke, burns
49AAP: Drugs of abuse for which adverse effects have been reported Amphetamine: irritability, poor sleeping patternCocaine: cocaine intoxication, irritability, vomiting, diarrhea, tremulousness, seizuresHeroin: tremors, restlessness, vomiting, poor feedingMarijuana: only one report in literature, no effect mentioned, very long half life for metabolites (see animal studies)
50Marijuana: 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
51AAP: AlcoholWith large amounts, drowsiness, diaphoresis, deep sleep, weakness, decrease in linear growth, abnormal weight gain, maternal ingestion of 1g/kg daily decreases milk ejection reflex.
52AlcoholCompatible with breastfeeding but use caution/moderation.
53CaffeineIrritability, poor sleeping pattern, excreted slowly, no effect with moderate intake of caffienated beverages (2-3 cups per day)General advise, use moderation.
54Drugs and LactationThomas Hale Medications and Mother’s Milk 11th edition 2004 Pharmasoft Publishing L.P., TexasGerald G. Brigs et al Drugs in Pregnancy and Lactation 7th edition 2005 Lippincott Williams and Wilkins
55What Advise would you give? Maternal diet and health?Diet modification for infants health?DHA, Vitamin Supplements, elimination diets
56What advice would you give? Drugs/medicationsSmokingCaffieneAlcohol“ 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?”