8 Maternal Nutrition During Lactation

Chapter 8: Maternal Nutrition During Lactation
California Food Guide

Maternal Nutrition During Lactation
By Paula Benedict Griffin, M.P.H., R.D.
What's New?
Exercise during lactation will not only improve
the mothers cardio respiratory fitness but may
increase the amount of essential fatty acids in
her breast milk.
1
Public Health Implications
Healthy People 2010 Objective 16-19: Increase the proportion of mothers
who breastfeed their babies. In the United States, by 2010, 75 percent of
mothers will breastfeed their newborns in the early postpartum period, 50 percent
will continue to breastfeed through their infants first six months and 25 percent
will breastfeed their babies throughout their first year of life.
2
Target and baseline:
3
Objective Increase in Mothers Who 1998 2010
Breastfeed Baseline Target
(unless
noted)
Percent of Mothers
16-19a. In early postpartum period 64% 75%
16-19b. At 6 months 29% 50%
16-19c. At 1 year 16% 25%
16-19d. Exclusively through 3 months 43% (2002) 60%
16-19e. Exclusively through 6 months 13% (2002) 25%
California Food Guide: Fulfilling the Dietary Guidelines for Americans
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1
In 2004, 83.9 percent of women in California intended to provide any
breastfeeding, to their newborn infants upon discharge from the hospital,
exceeding the Healthy People 2010 target of 75 percent of mothers
breastfeeding in the early postpartum period. However, only 40.5 percent
intended to exclusively breastfeed, thus, the Healthy People 2010 Objective
16-19 d. target of 60 percent was not met in California (see Figure 1).
Definition
Lactation, the process of milk secretion, is sometimes referred to as the
physiological completion of the female reproductive cycle. During pregnancy,
hormonal action prepares the female mammary glands to produce milk, which
will continue to be produced in the postpartum period in response to the infant
suckling at the breast.
4
Also during pregnancy a womans body prepares to breastfeed by storing
additional nutrients and energy needed for milk production. Breast milk provides
sufficient calories and nutritive factors to allow an infant to double its birth weight
by six months of age. Breast milk is a bioactive, complex fluid containing more
than 200 recognized substances varying in composition between women, and
from the same woman, depending upon her stage of lactation.
5
Breast milk of
women who deliver a premature infant is higher in calories, fats, protein, immune
factors, and anti-inflammatory agents compared to full-term breast milk,
therefore, adaptive to the additional nutritional needs of the premature infant.
Maternal nutritional requirements during lactation have been studied in women
from many cultures, and while much has been learned, some information is
conflicting because of differences in sampling techniques and laboratory analysis
methods. However, many studies have documented that lactation and infant
growth are not compromised when maternal intakes fall below recommended
levels for vitamins, minerals, and energy. The nutritional quality of breast milk
remains fairly constant, even when the mothers supply of nutrients is limited on a
short-term basis.
6, 7
Benefits of Breastfeeding
The American Academy of Pediatrics (AAP) recommends that infants be
breastfed without supplemental foods or liquids for their first six months of life,
and that breastfeeding should be continued for the first year of life and beyond,
as mutually desired by the mother and child.
8
Additional discussion of the
nutritional benefits of breastfeeding for the infant is contained in the Normal
Infant Feeding (0-12 months) chapter.
In addition to being the optimal method to nourish an infant, breastfeeding
provides many health benefits for the mother. These benefits include more rapid
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2
recovery from childbirth; decreased postpartum bleeding; delayed return to
fertility; reduced risk for breast and ovarian cancers; less bladder and other
infections; possibly less post-menopausal hip and spinal fractures; and reduced
risk for developing type 2 diabetes.
8, 9, 10, 11
Many lactating women return to their
pre-pregnancy weight more quickly than bottle-feeding mothers.
12
Additional
health benefits cited by Riordan are lower serum levels of cholesterol and
triglycerides in breastfeeding women compared to women who gave their babies
manufactured infant milk (formula).
12
Nearly every woman is physically capable of breastfeeding. According to the
CDC, women who are infected with the hepatitis C virus (HCV) can breastfeed,
but should temporarily discontinue breastfeeding if the nipples or surrounding
areola become cracked and bleeding. The breast milk can be expressed and
discarded while the nipples heal.
13
However, in some cases a woman should not breastfeed because doing so
would place the mother or the infant at risk for an adverse health outcome,
surpassing the benefits of breastfeeding.
4
A mother with a new diagnosis of
breast cancer or women who are unable to consume less than two alcoholic
drinks per day, who currently use street drugs such as heroin or cocaine, and
women who have tested positive for the human immunodeficiency virus (HIV)
should not breastfeed, and should discuss their infant feeding plans with their
health care provider.
14
However, in developing countries, breastfed infants may
be better protected from HIV transmission from their mothers compared to infants
given manufactured baby formula. One large study found exclusively breastfed
infants of HIV-positive mothers had a significantly lower risk of HIV transmission
compared to partially-breastfed or formula-fed babies. It was speculated that the
exclusively breastfed infants superior intestinal mucosal barrier prevented HIV
transmission.
12
In developing countries, the health risks of not breastfeeding
outweigh the possible risk of HIV transmission, due to increased infant mortality
from infectious diseases and nutritional deficiencies.
15
Incidence and Prevalence
Breastfeeding rates are lower in the United States compared to other countries.
Only 17 percent to 20 percent of infants in the Unites States are breastfed for 12
months, compared to 79 percent worldwide. Since the 1970s, breastfeeding
initiation rates have increased from a low of about 24 percent to a high of 70
percent in 2002.
9
Trends/Nutrient Patterns
As shown in Figure 1, Californias rates for any breastfeeding, a measure of
mothers who are exclusively breastfeeding and those who give both breast milk
and manufactured baby formula to their infants, increased from 71.9 percent to
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3
83.9 percent, between 1992 and 2004, while exclusive breastfeeding rates
remained relatively stable, with a slight decline since the late 1990s.
Breastfeeding rates differ between ethnic groups, as illustrated in Figure 2.
Between 1992 and 2004, Whites, American Indians, and women of multiple
race/other had higher in-hospital exclusive breastfeeding rates, while African-
American, Pacific-Islander, and Latina rates were lower. Additional information
regarding the incidence and duration of breastfeeding in different ethnic groups in
California can be found in the Normal Infant Feeding (0-12 months) and the
Health and Dietary Issues Affecting Latinos chapters of this guide.
Figure 1: Breastfeeding Rates in California as Reported on the Newborn
Screening Test Form (1992-2004)
16 *
40.5%
41.2%
41.8%
42.2% 42.6%
42.9%
43.5%
42.8% 41.8%
42.2%
42.9%
41.5%
40.3%
83.9% 83.6% 83.5% 82.9%
82.0%
81.0%
80.3%
78.3%
76.4%
74.7%
74.2%
73.1%
71.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Exclusive BF Any BF
*

Any breastfeeding includes women exclusively breastfeeding and women who are both
breastfeeding and giving manufactured infant formula.
**Data Source: Newborn Screening Data Base, Genetic Disease Branch, California
Department of Health Services, 1992-2004.
4
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Figure 2: Exclusive Breastfeeding Rates by Ethnicity 1992-2004
16
0%
10%
20%
30%
40%
50%
60%
70%
1992 1993
1994
1995
1996 1997 1998
1999 2000
2001
2002
2003 2004
African American American Indian Asian Latino
Pacific islander White
Multiple Race/Other
TOTAL
Data Source: Newborn Screening Data Base, Genetic Disease Branch, California
Dietary Recommendations
Women who are breastfeeding do not need to consume special foods or
excessive amounts of fluid to successfully lactate or to increase their milk
production.
12
Dietary restrictions are unnecessary, unless certain foods are
suspected allergens to the baby. The belief that a womans diet must be
perfect during lactation is not accurate; women with a wide range of dietary
habits and customs worldwide are consistently able to nourish their infants to
grow and develop properly. Guidance given to lactating women should be
carefully weighed in consideration of the misconception that the maternal diet
must be perfect in order to produce quality breast milk.
17
Lactating women
5
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should be encouraged to obtain their nutrients though a well-balanced diet, rather
than vitamin and mineral supplements,
5
and consume a variety of foods using
MyPyramid
18
as a guide to food choices.
Four overarching themes within the MyPyramid Education Framework provide a
basis for dietary guidance for healthy individuals:
18
(1) VarietyEat foods from all food groups and subgroups.
(2) ProportionalityEat more of some foods (fruits, vegetables, whole grains,
fat-free or low-fat milk products), and less of others (foods high in
saturated or trans fats, added sugars, cholesterol salt, and alcohol).
(3) ModerationChoose forms of foods that limit intake of saturated or trans
fats, added sugars, cholesterol, salt, and alcohol.
(4) ActivityBe physically active every day.
The 2005 Dietary Guidelines identifies breastfeeding women with different
nutritional requirements than other population groups. Key recommendations for
lactating women are listed below in Table 1, and a comprehensive list of nutrient
recommendations during lactation is included in Appendix 1.
Table 1: Key Recommendations for Breastfeeding Women from the Dietary
Guidelines for Americans 2005
19
Weight Reduction
Moderate weight reduction is safe and does not compromise weight gain of the nursing
infant.
Physical Acti vity
Neither acute nor regular exercise adversely affects the mother's ability to successfully
breastfeed.
Alcoholic Beverages Alcoholic beverages should not be consumed by some individuals, including those who
cannot restrict their alcohol intake, women of childbearing age who may become pregnant,
pregnant and lactating women, children and adolescents, individuals taking medications that
can interact with alcohol, and those with specific medical conditions.
The nutritional profile of breast milk stays remarkably uniform over a wide range
of dietary intakes. When the maternal diet is limited, levels of protein,
carbohydrate, fat, folate, and most minerals are maintained at consistent levels in
her breast milk at the expense of nutrient stores.
5
In women with adequate
vitamin and mineral status, fluctuations in micronutrient intakes are not reflected
in milk composition.
Nutrient needs during lactation are a function of the womans nutrient needs and
status, and her output of breast milk. Her needs will be greater if she is feeding
twins or triplets, and less if she is only partially breastfeeding an infant who is
also receiving formula or complementary solid foods.
5
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6

Daily Food Choices for Lactating Women
The Dietary Guidelines for Americans 2005 (Dietary Guidelines) does not provide
detailed recommendations for lactating women; however, MyPyramid for Moms
provides guidance for the daily servings of foods and calories based upon
information entered at its website:
www.mypyramid.gov/mypyramidmoms/breastfeeding_nutrition_needs.html,
including age of the baby, amount of breastmilk and formula being given to the
baby, and age and physical activity level of the mother. Table 2, Daily Food
Choices for Lactating Women, is an adaptation of recommendations made in the
Dietary Guidelines and MyPyramid, and can serve as a guide to meal planning.
While this is only a guide and may not be suitable for all breastfeeding women, it
can assist women in obtaining their recommended intakes of nutrients from the
food groups.
Energy Needs During Lactation
Energy or caloric needs during lactation are based upon the womans basal
metabolic rate, age, activity level, how much breast milk is being produced, and
other factors. While calories are needed for milk production, the mother does not
need to eat substantially more than she did in her pre-pregnancy state to sustain
milk production.
12
In most cases, a woman who consumes 500 calories (kcal) per day above her
pre-pregnancy intake will be able to maintain her body weight during the first six
months postpartum and will have sufficient calories for milk production. After six
months postpartum, an extra 400 kcals/day is normally sufficient. These
recommendations are based on the average energy expenditure of moderately
active women, the estimated caloric cost of lactation, and take into account some
fat mobilization from maternal stores, equal to approximately 170 kcal/day.
20, 21, 22
It is recognized that these guidelines allow for wide variance in energy
expenditure and represent the upper limit within the recommended range for
additional calories, and many women will require fewer calories to avoid weight
gain.
12
A significant maternal energy deficit appears to reduce the quantity, but not the
quality of breast milk. Energy intakes less than recommended levels are seen in
women attempting to lose weight, those who are inactive or otherwise have low
energy needs, or are food insecure.
Calorie intakes of 1,800 per day or above are recommended for lactating women,
and should not consistently fall below 1,500 per day during lactation or milk
supply could be compromised.
5, 20
However, due to differences in tissues stores
and metabolic and activity needs between women, it is unrealistic to determine a
critical energy level necessary for adequate milk production for all women.
22
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7
While the milk supply of well nourished women does not appear to be negatively
affected by short-term energy intakes below current recommendations,
23, 24
undernourished women may benefit from supplemental food. A study of
undernourished Guatemalan women supplemented with approximately 280 kcal
per day resulted in improved milk production and the duration of exclusive
breastfeeding.
25
Table 2: Daily Food Choices for Lactating Women
18, 19
(2200-2800 calories)*
Food Groups Recommended
# of Servings
Serving Sizes and Food Choices
Grains 7-10 choices of
these 1 ounce
equivalents
A 1 ounce equivalent is:
1 slice whole grain bread
1 cup dry cereal
cup cooked cereal, rice, pasta
1 roll, pancake, small tortilla
bagel or English muffin
4 crackers
Vegetables 3 cups Raw or cooked vegetables such as carrots,
broccoli, sweet potatoes, spinach, pumpkin,
squash, peppers, tomatoes, greens, cabbage,
snow peas, leafy greens, 100% vegetable juice,
corn, potatoes, legumes. Aim for these amounts
each week: 3 cups dark green veggies, 2 cups
orange veggies, 3 cups legumes, 7 cups starchy
veggies, and 8 cups of other veggies.
Fruits 2 cups Choose fresh, frozen, canned fruit or 100% juice.
Medium whole fruit= cup
cup dried fruit= 1 cup fresh fruit
Milk 3-4* of these
choices
*4 for teens
1 cup low-fat or fat-free milk or yogurt
1 ounces cheese
2 ounces of low-fat cheese
1 cup pudding or custard made with milk
1 cups frozen yogurt or ice cream
1 cup calcium- fortified, lactose-free milk or soy
milk
Meat & Beans 6-7 choices of
these 1 ounce
equivalents
A 1 ounce equivalent is:
1 ounce of cooked lean meat, poultry, or fish
1 egg
cup cottage cheese
cup cooked dry beans, peas, lentils
cup tofu
1 Tablespoon of peanut butter
ounce nuts or seeds
Oils 6-8 teaspoons Vegetable oil, soft margarine, mayonnaise, salad
dressing
Discretionary
Calories
290-426 Discretionary Calorie Allowance is the remaining
amount of calories in a food intake pattern, after
accounting for the calories needed for all food
groups using forms of foods that are fat-free or low-
fat, and with no added sugars.
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8
*Source: Adapted from the 2005 Dietary Guidelines for Americans and MyPyramid. Based on
recommendations that lactating women, in the normal weight range, need an additional 500
calories per day.
Key Nutrients for Women during Lactation
Nutrients are mobilized from maternal stores to produce breast milk, and the
lactating woman is vulnerable to depletion of her nutrient stores. She should be
encouraged to consume foods high in calcium, vitamins A, B
1
(thiamin), B
2
(riboflavin), vitamin B
6
, B
12
, folate, and iodine to minimize losses and to maintain
her health and well-being.
5, 19
Calcium
Calciums role in the body is to assist with blood clotting, muscle contraction,
nerve transmission, and the formation of bone and teeth.
26
Calcium is mobilized
from the bone during lactation and then replenished later. The calcium content of
breast milk is maintained at the expense of maternal stores, and does not appear
to be affected by the womans serum calcium levels or dietary intake and
supplementation. Women experience temporary acute bone mineral loss during
lactation, only to have bone density restored to normal or above baseline after
weaning.
4, 17
During lactation, alterations in metabolism, absorption, and
excretion appear to help preserve maternal calcium stores.
4
The Food and Nutrition Board of the Institute of Medicine recommends that
women 19-50 years of age consume 1,000 milligrams (mgs) of calcium per day,
and teens aged 14-18 years consume 1,300 mgs.
26
Milk and milk products are
excellent sources of calcium, and non-dairy sources include calcium-fortified
breakfast cereals, juices, and soy milk, calcium-set tofu, Chinese cabbage, kale,
broccoli, and canned fish with bones, such as sardines and salmon.
Calcium supplements should be considered for women who do not consume milk
or milk products or a regular source of dietary calcium. In the case of lactose
intolerance, Lactaid milk, yogurt, or hard cheeses may be acceptable sources
of calcium. Please refer to the Milk and Milk Products chapter of this guide for
additional information.
Vitamin A
Vitamin A is required for vision, immune system function, and maintenance of
epithelial tissue.
26
The vitamin A content of breast milk is influenced to a greater
extent by maternal dietary intake than by the womans vitamin A status.
4, 17
Infants are born with relatively small amounts of stored Vitamin A in the liver and
rely heavily on intake from breast milk or other dietary sources. However,
vitamin A deficiency in breastfed infants is quite rare, as breast milk is a good
source of the vitamin.
12
Lactating women should consume an extra 600 g of
vitamin A per day, according to the DRIs.
26
Fortified milk, liver, and dark green
and orange colored fruits and vegetables are good sources of vitamin A or its
precursor, beta carotene.
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9
Vitamin B
1
(Thiamin)
Thiamin plays an important role as a coenzyme in the metabolism of
carbohydrates and branched-chain amino acids.
26
Breastfed infants of women
with beriberi, the thiamin deficiency disease, consequently develop infantile
beriberi by three to four weeks of age.
27
In thiamin-deficient women,
supplementation will increase levels in breast milk to a certain limit, while excess
is excreted in the urine.
4
An additional 0.3 mg of thiamin per day is recommended during lactation,
26
easily
obtained from a slice of enriched bread. Due to the enrichment of grains, thiamin
deficiency in the United States has become rare.
Vitamin B
2
(Riboflavin)
Riboflavin also functions as a coenzyme involved in many reactions in the body.
As with all the B vitamins, except folate, maternal intake of riboflavin is reflected
in breast milk.
4
Women who are deficient in riboflavin produce breast milk that is
low in riboflavin, but is responsive to supplementation.
During lactation, the recommended extra 0.5 mg per day
26
can be obtained from
a glass of milk and enriched grains. Since grains in the United States have been
enriched with riboflavin, deficiencies are rare.
B
6
(Pyridoxine, pyridoxal, and pyridoxamine)
Vitamin B
6
functions as a coenzyme in the metabolism of amino acids and
glycogen.
26
The B
6
content of breast milk is directly related to maternal intake
and has been known to drop to critically low levels in mothers with a long-term
history of oral contraceptive use.
4
However, modern formulations of oral
contraception contain lower levels of estrogens than those previously studied,
and the effect on B
6
status in breast milk is not clear.
5
Very high doses of vitamin B
6
have been shown to suppress lactation by
reducing prolactin levels, thus lactating women taking supplements should not
take more than 25 mg of B
6
per day.
28
An extra 0.7 mg of pyridoxine per day is recommended during lactation,
26
which
can be easily consumed in a bowl of fortified breakfast cereal.
Vitamin B
12
(Cobalamin)
Vitamin B
12
functions as a coenzyme in nucleic acid metabolism. Deficiency of
this vitamin has been seen in infants breastfed by mothers who were very strict
vegetarians. Maternal supplementation should be considered for women who
may have very low B
12
stores, such as total vegetarians (vegans) who consume
no animal-based foods or beverages, or those with Crohns Disease, a history of
gastrectomy or parasitic or gastrointestinal bacterial infection. Long-term
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10
neurological problems can result from vitamin B
12
deficiency during infancy.
27, 29,
30, 31
An extra .04 g of Vitamin B
12
is recommended daily during lactation, and is
easily obtained from milk, eggs, meat, fish, poultry, or enriched cereals or grains.
Folate (Folic Acid, Folacin)
Folic acid has been recognized for its role in the prevention of neural tube
defects. In 1992, the U.S. Public Health Service recommended that all women of
childbearing age consume 0.4 mg (400 micrograms) of folic acid daily to prevent
two common and serious birth defects, spina bifida, and anencephaly.
While severe maternal folate deficiency can influence the folate content of breast
milk, milk production appears to take priority in folate utilization. This was
illustrated in a study involving overtly folate deficient women with megaloblastic
anemia. The women were supplemented with folate and the researchers
observed an increase in the folate content of the womens breast milk, however,
no change was seen in their plasma folate levels.
32, 33
In 1998, all grain products manufactured in the United States were required to be
fortified with folic acid. Orange juice, fortified breakfast cereals, and dark green
vegetables are good sources of folic acid.
Iodine
Iodine is a component of the thyroid hormones and is essential to prevent goiter
and cretinism.
26
Iodine levels in breast milk vary based upon maternal intake and
are strongly influenced by maternal intake. Pregnant and lactating women in
geographic areas where iodine deficiencies are prevalent should be
supplemented with iodine to prevent brain damage and mental retardation in their
children.
32, 34
In the United States, iodized table salt is a good source of this
mineral.
Protein
Protein needs are greater for women during lactation compared to non-
pregnancy. The Food and Nutrition Board of the Institute of Medicine has set the
Recommended Dietary Allowance (RDA) for lactating women of all ages at 71
grams of protein, using 1.1 grams of protein per 1 kilogram reference body
weight, with an acceptable range of intake between 10 and 35 percent of total
calories.
35
Consumption of a variety of six 1- ounce equivalents from the Meat
and Beans Group and three servings from the Milk Group helps to meet this
need.
The protein content in breast milk appears to be influenced very little by maternal
diet and is more affected by the age of the infant.
17
Proteins are synthesized in
the breast based on gene expression, which is influenced by changing hormone
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11
levels in the weeks and months after delivery.
36
While the protein content of
human breast milk is low in comparison to other mammalian species, breast milk
proteins provide appropriate amounts of amino acids vital for the proper growth
of the infant. Breast milk proteins also provide antiviral, antimicrobial, and anti-
inflammatory factors to protect the infants system.
35
Carbohydrate
Carbohydrates provide a readily available source of energy to the body and are
present in nearly all foods that have calories, except fats and oils. A womans
RDA for carbohydrates increases to 210 grams during lactation.
22
Lactose is the
major carbohydrate in breast milk and is second only to water as a major
constituent of breast milk. Lactose content in breast milk is similar between
women, and does not appear to be affected by maternal diet.
5
Fat
The total fat content of breast milk remains consistent independently of the
mothers diet. However, the types of fatty acids present in breast milk are
influenced by maternal diet and energy balance.
37, 38
A woman with a diet high in
monounsaturated fatty acids would have a large amount of this type of fatty acid
reflected in her breast milk. This is also true for DHA (docosahexaenoic acid),
recognized for its important role in retinal development. When a woman loses
weight while lactating, the breast milk contains the types of fatty acids found in
her adipose tissue.
The breast milk of women who deliver prematurely is higher in long chain
polyunsaturated fatty acids, consistent with the premature infants greater need
for these fatty acids necessary for growth and brain development.
32
Although a mothers dietary fat intake may vary on a daily basis, hormonal
changes during lactation allow for the production of breast milk with a fatty acid
content appropriate for the baby.
32
RDAs for fat intake have not been
established, however, an acceptable range for adults is 20-35 percent of total
calories, with the recommendation that saturated fat and trans fatty acid
consumption be kept as low as possible with a nutritionally adequate diet.
22
Fluid intake
Breast milk production and volume is not affected by short-term increases or
decreases in fluid intake. However, excessive fluid intake has been shown to
negatively affect milk production in a study by Dusdieker, as cited in Lawrence &
Lawrence.
4
Women can be advised to have a beverage nearby while they are
breastfeeding their baby, but only need to drink in response to thirst. Adequate
hydration is best indicated by passing urine with a pale yellow color,
17
however,
women taking certain medications or multivitamins may find their urine color to
be altered and should not depend solely on urine color as a guide to hydration
status.
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12
Vitamin and Mineral Supplements
A lactating woman should not routinely depend upon a multivitamin supplement
to meet her nutritional needs. However, women with very restricted diets, such
as vegans, or who regularly consume less than 1,800 calories per day could
benefit from calcium and multivitamin supplements.
5
A nutritional assessment
from a health care provider can reveal if a woman could benefit from a
multivitamin supplement.
In 1992, the U.S. Public Health Service recommended that women of
childbearing age consume 400 micrograms of folic acid per day to reduce their
risk of having a pregnancy affected by a neural tube defect (NTD). Since
lactating women are of childbearing age, a daily folic acid supplement or
multivitamin with folic acid is advised. Supplementation with folic acid in women
before conception and during early pregnancy has been shown to reduce the
occurrence of NTDs by at least 50-70 percent.
39
Other Vitamins and Minerals during Lactation
Vitamin D
The vitamin D content of breast milk is influenced by maternal vitamin D status,
and breast milk does not typically provide enough to meet infant needs. Infants
rely on stored vitamin D as well as adequate exposure to sunshine, equivalent to
two hours per week while fully clothed. Infants breastfed by mothers who restrict
their intake of vitamin D-rich foods, or have severely limited exposure to sunlight
can develop rickets due to a vitamin D deficiency.
32
See the Normal Infant
Feeding (0-12 months) chapter of this guide for additional information.
Iron
In contrast to pregnancy, the recommended intake for iron during lactation is not
increased, and is actually lower than that of a non-pregnant female. The RDA for
iron during lactation is nine grams for women 19-30 years of age, versus 18
grams for the non-pregnant female and 27 grams for pregnant women of the
same age. These recommendations for intake are based on menstruation
resuming at six months postpartum and iron losses in breast milk and normal
metabolic processes, but does not take into account the high prevalence of iron-
deficiency anemia in women of childbearing age and the need to recover iron
stores after pregnancy.
23
The iron content of breast milk does not appear to be related to maternal dietary
intake. Iron supplements taken by the mother will not increase iron levels in
breast milk, even if the mother is anemic. In women, iron-deficiency anemia has
been associated with postpartum depression.
40
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13
Barriers to Implementations/Myths
Postpartum Weight Loss
Although the caloric cost of breastfeeding has been estimated at 670 calories per
day, and the hormonal environment favors the mobilization of fat stores, most
lactating women lose weight at a relatively slow rate during the first six months
postpartum, ~0.8 kg/mo in affluent populations and ~0.1 kg/mo in disadvantaged
populations. Differences in mean weight changes are likely due to differences in
gestational weight gains, cultural practices, physical activity level, and seasonal
food availability.
41
Weight loss in the first six months postpartum is normally 0.5-1.0 kg (~1-2
pounds) per month; however, not all lactating women lose weight. Overweight
women can lose up to 2.0 kg (~4.5 pounds) per month without adverse effects on
milk production.
5
Intentional weight loss should not be attempted until two months postpartum, and
then at a rate of no more than 2 kg (~4.5 pounds) per month, consuming a diet of
at least 1,800 calories per day.
5
This loss should be managed with a
combination of changes in food intake and increased physical activity.
For women motivated to lose weight at a somewhat increased rate, a modest
reduction in caloric intake does not appear to influence breast milk composition
or volume.
20
A study involving well-nourished women, found that milk production
was not compromised during a ten week weight loss program that included a 23
percent reduction in energy intake and resulted in a weekly weight loss of one
pound.
42
A recent study with overweight lactating women who decreased their energy
intake by 500 calories per day, primarily by restricting chips, soft drinks, and
other fats and sweets, had nutrient intakes comparable to a group of overweight
lactating women who did not restrict their intake. However, the restricted group
consumed one less serving of milk and had lower vitamin D and calcium intakes
than the control group. Both groups had low intakes of vitamin C and E.
43
Colic and Maternal Diet
It is commonly believed that eating certain foods, such as onions, garlic, and
broccoli can cause a colicky baby. However, few studies have shown any
association between these foods and infant distress. Women should presume
that all foods will be tolerated well by the infant and only eliminate specific foods
after they have been demonstrated as problematic for the baby. If a mother is
concerned that her infant is reacting to her diet, she should keep a record of the
food she eats and information about her babys response, including symptoms
and/or behaviors and discuss any concerns with her health care provider.
4, 17
8/23/06
14
Maternal Intake of Food Allergens
Breastfeeding offers protection from both respiratory and food allergies
throughout childhood and adolescence. However, if a breastfed baby shows
allergic symptoms, the mother should consider avoiding the major food allergens-
-wheat, peanuts, soybeans, tree nuts, eggs, cows milk --for ten to14 days. If the
infant shows a reduction in symptoms, the foods can be reintroduced one at a
time to help identify the cause. The most common food allergen for infants is
cow milks protein, which can be ingested from whole milk, manufactured baby
formula, or passed through the breast milk from the mother.
12
Vegetarianism and Lactation
Vegetarian mothers should be encouraged to breastfeed as they produce breast
milk with a similar composition to that of non-vegetarian women. However,
vegetarian diets must include regular sources of vitamin B
12
, calcium, and vitamin
D. Vitamin B
12
is found naturally in foods of animal origin, and sometimes added
as a supplement to plant-based food products. Vegetarians who do not use milk
and milk products need good alternate sources of calcium, protein, and vitamins
B
2
, B
12
, and D.
19
Docosahexaenoic acid (DHA) is an essential fatty acid that plays a role in infant
brain and eye development. Vegans and other vegetarians who not do regularly
eat eggs should be encouraged to include sources of linolenic acid, a DHA
precursor. DHA has been measured in breast milk of vegetarian women at lower
levels than in non-vegetarians. These women should also be encouraged to limit
their intake of foods containing linoleic acid, such as corn, safflower and
sunflower oil, and limit foods with hydrogenated fats, such as stick margarine, as
they hinder the conversion of linolenic acid to DHA.
44
Additional information about vegetarianism can be found in the Vegetarian Diets
chapter in this guide.
Physical Activity and Lactation
Milk production appears to be protected when lactating women participate in
exercise and increase their energy expenditure. Several factors may be involved
including an increase in energy intake and an increase in prolactin levels.
Several studies suggest that lactating women will increase energy intake to
compensate for any increase in energy expenditure due to a physical activity
program, with no apparent effect on milk production or infant growth.
45, 46
Additionally, in response to aerobic activity, there is an increase in fatty acid
mobilization to meet the needs of milk production.
32
Caffeine and Lactation
Caffeine is a stimulant found in many foods, beverages, and over-the-counter
medications. Products such as energy beverages, weight loss aids, and herbal
supplements may also contain caffeine. Caffeine concentration peaks in breast
milk one to two hours after consumption. While adults can metabolize a large
8/23/06
15
amount of caffeine within five hours, this process can take nearly 20 times longer
in a newborn. Irritability and sleeplessness in the breastfed infant after maternal
caffeine consumption has been described.
28
Chronic coffee drinking may also reduce the amount of iron in breast milk.
Chronic and persistent ingestion of caffeine during lactation should be avoided,
especially during the first few months of the infants life; however, occasional use
of caffeine is not contraindicated during lactation.
28, 47
If a baby appears to be
responding to the caffeine in the mothers diet, all caffeine-containing products
should be avoided for two to three weeks.
48
Alcohol and Lactation
Although wine and beer have been recommended to improve lactation, this has
proven untrue. Studies suggest that alcohol can impair milk ejection and cause a
reduction in milk volume.
49
Peak breast milk levels are seen 30-60 minutes after alcohol consumption and at
60-90 minutes when accompanied by food. As alcohol is metabolized by the
womans liver, her plasma and milk levels decline. Clearing the equivalent of one
serving of beer or wine from a 120-pound womans body has been estimated to
take two to three hours.
4, 50
Studies show that maternal ingestion of alcohol changes the odor of the breast
milk and can reduce the volume consumed by the infant by as much as 20
percent. Even short-term exposure to small amounts of alcohol in breast milk
has been shown to result in a decrease in the total sleep time for the infant.
50
Smoking, Nicotine, and Lactation
Maternal smoking is associated with reduced milk volume, impaired milk ejection
reflex, and early weaning. However, breastfed infants of mothers who smoke
receive better protection than bottle-fed babies with less acute respiratory illness
8
and risk for Sudden Infant Death Syndrome (SIDS). Women who are unable to
quit should be advised to not smoke while nursing or in the presence of the
infant.
4, 51, 52, 53
Studies have shown that using a 14-mg or seven-mg nicotine patch offers a
sustained and lower nicotine level than smoking and appears to not affect the
milk intake of the breastfed infant. However, nicotine gum may cause significant
peaks in plasma nicotine levels and it is recommended that mothers wait two to
three hours after using the gum product to breastfeed.
28
Herbal Products, Over the Counter Medications, and Prescription Drugs
during Lactation
Several herbal preparations are marketed with the promise to either increase or
decrease milk supply. However, some herbal supplements are incompatible with
successful lactation while others can be dangerous to the womans health. Since
8/23/06
16
herbal preparations and dietary supplements are not regulated as medications,
their active ingredients, safety, efficacy, potency, and purity are unknown.
54, 55
Fenugreek is an herbal substance with a widespread reputation as a
galactagogue, a substance which increases milk production; yet its efficacy is not
supported by scientific evidence. While this product has limited toxicity when
consumed in moderation, a few cases of adverse side effects have been
reported.
28
Most non-prescription, over-the-counter medications pose little or no risk of harm
to a breastfed infant. However, aspirin, implicated in Reyes syndrome, and
pseudoephedrine, which can dramatically reduce milk production, should be
avoided during lactation, and better alternatives such as ibuprofen and
acetaminophen could be used under the guidance of a health care provider.
28
The recommendation to reduce or discontinue breastfeeding due to maternal
medication should only be made when no alternative drug can be given and the
risk to the baby significantly outweighs the benefits of breastfeeding.
17
Breastfeeding women should discuss their use of herbal products or medication
with their health care provider in order to select the best option during lactation.
14
Illicit Drugs and Lactation
Most drugs pass to some extent into breast milk. The active ingredient in
marijuana, delta-9-tetrahydrocannabinol (THC), concentrates in breast milk prior
to entering the infants circulatory system and can result in impaired infant motor
development at twelve months of age.
56
Other drugs of abuse, such as heroin,
cocaine, the hallucinogens, and methamphetamines pass into breast milk and
can have detrimental effects on the infant.
12
Women who are currently using illegal, recreational drugs should be advised of
the effect of these substances on their infants, and that their infants will be drug-
screen positive for as long as a few weeks after ingestion. The lactating woman
who is unable to remain drug-free should discuss her infant feeding plans with
her health care provider, and should probably be advised to bottle-feed.
12
Opportunities for Improvement
(1) Assure lactating women are assessed for nutritional adequacy and the
use of tobacco, alcohol, drugs, herbal products, and over-the-counter
medications, and have access to appropriate counseling and referral
sources.
(2) Support measures to provide pre-conception nutrition and healthy lifestyle
education and counseling, including the importance of a daily 400 mcg.
folic acid supplement, and appropriate child spacing to allow recovery of
maternal nutritional status.
8/23/06
17
(3) Support an environment where lactating women can comfortably
breastfeed their babies, without fear of ridicule or unwarranted reprisal.
(4) Support communities that provide reduced exposure to tobacco, alcohol,
and drugs to all women of childbearing age.
This chapter was reviewed by Suzanne Haydu, MPH, RD, Janet Hill, MS, RD,
IBCLC, of the California Department of Health Services (CDHS), Maternal, Child,
and Adolescent Health and Office of Family Planning Branch, Jeanette Panchula,
RN, IBCLC, of CDHS and Solano County Health and Human Services, and
Lindsay Bowersox, RD, IBCLC, Dietitian and Lactation Consultant, Community
Medical Centers WIC Program and UC Davis, MS Graduate Program.
Significant contributions to this chapter were made by original author Timaree
Hagenburger, MPH, RD. Additional contributions to this chapter were made by
Natalie Melcher, B.A. and Jacqueline Kampp, PHN, MS, RN.
8/23/06
18

Appendix 1: Nutrient Recommendations for Lactating Women
(19, 22, 26)
Nutrient Dietary Reference
Intake (DRI) for non-
pregnant, non- lactating
women (per day)
19-50 yrs
Additional amount
above DRI
recommended for
Lactating Women (per
day) 19-50 yrs
Tolerable Upper Intake
Level (UL)
(per day)
Food Sources
Protein 50 g
+15 g (0-6 mo
postpartum)
+12 g (6-12 mo
postpartum)
Not determined Meat, fish, poultry, dry
beans, eggs, tofu,
cheese, nuts, seeds
Carbohydrates-- total
digestible
130 g +80 g Not determined Grains, pasta, starchy
vegetables, fruit and
fruit juices
Total Fiber 25 g +4 g Not determined.
Excessive intake can
cause gastrointestinal
distress and is usually
self-limiting.
Whole grains,
vegetables, whole fruit,
dry beans, nuts
Total Fat Not determined Not determined No defined excessive
intake level for potential
adverse effects
Whole milk, meats,
vegetable oils, butter
Linoleic acid (n-6
polyunsaturated fatty
acids)
12 g +1 g No defined excessive
adverse effects
Nuts, seeds, vegetable
oils
Linolenic (n-3
polyunsaturated fatty
acids)
1.1 g +.2 g No defined excessive
adverse effects
Vegetable oils, flax
seed, fatty fish, fish oils,
eggs
Fat-Soluble Vitamins
Vitamin A 700 g +600 g 3,000 g Liver, fish, dairy
products, darkly-
colored fruits and leafy
vegetables
Vitamin D 5 g ----- 50 g Fortified dairy products
Vitamin E 15 mg + 4mg 1000 mg Nuts, vegetable oils
Vitamin K 90 g ---- Not determined Leafy green
vegetables, Brussels
sprouts, broccoli,
vegetable oils.
Water-Soluble Vitamins
Vitamin B
1
Thiamin 1.1 mg +0.3 mg Not determined Enriched, fortified, or
whole-grain products
Vitamin B
2
(Riboflavin)
1.1 mg +0.5 mg Not determined Organ meats, milk,
bread products and
fortified cereals
Vitamin B
3
(Niacin) 14 mg +3 mg 35 mg Meat, fish, poultry,
19
8/23/06

(19, 22, 26)
women (per day)
19-50 yrs
Additional amount
above DRI
recommended for
day) 19-50 yrs
Level (UL)
(per day)
Food Sources
whole grain breads and
bread products, fortified
cereals
Vitamin B
6
(Pyridoxine,
Pyridoxal, and
Pyridoxamine)
1.3 mg +0.7 mg 25 mg Fortified cereals, organ
meats, fortified soy-
based meat substitutes
Vitamin B
12
(Cobalamin)
2.4 g +.04 g Not determined Meat, fish, poultry,
fortified cereals
Folate 400 g +100 g 800 g Enriched cereal grains,
fortified ready-to-eat
cereals, dark green
leafy vegetables
Vitamin C 75 mg +45 mg 2,000 mg Citrus fruit,
strawberries, bell
pepper, broccoli,
cabbage, spinach,
tomatoes
Pantothenic Acid 5 mg +2 mg Not determined Whole grains, poultry,
yeast, potatoes,
broccoli
Biotin 30 g +5 g Not determined Liver, some meats and
fruit
Choline 425 mg + 125 mg 3,500 mg Eggs, liver, milk,
peanuts
Minerals
Calcium 1,000 mg
1,300 mg (14-18 yrs)
--- 2,500 mg Milk and milk products,
Chinese cabbage, kale,
broccoli, calcium-set
tofu
Potassium 4.7 g +0.4 g Not determined Fruits, vegetables.
dried peas, dairy
products, meats, nuts
Phosphorus 700 mg --- 4000 mg Milk and milk products,
eggs, peas, meat
Magnesium 310 mg (19-30 yrs)
320 mg (31-50 yrs)
--- 350 mg only when
consumed in supplemental
for. No UL established for Mg
Green leafy vegetables,
unpolished grains, nuts,
meat, milk
20
8/23/06

(19, 22, 26)
women (per day)
19-50 yrs
Additional amount
above DRI
recommended for
day) 19-50 yrs
Level (UL)
(per day)
Food Sources
consumed from foods.
Manganese 1.8 mg +.8 g 11 g Nuts, legumes, tea,
whole grains
Chloride 2.3 g --- 3.6 g Processed foods with
added sodium chloride,
salted meats, nuts, cold
cuts
Chromium 25 g + 20 g Not determined Some cereals, meats,
poultry, fish, beer
Copper 900 g +400 g 10,000 g Organ meats, seafood,
nuts, seeds, whole
grains
Fluoride 3 mg ---- 10 mg Fluoridated water, teas,
marine fish
Iodine 150 g +140 g 1,100 g Iodized salt, foods of
marine origin
Iron 18 mg less 9 mg 45 mg Meat, poultry, fortified
breads and grains, dry
beans
Selenium 55 g; +15 g 400 g Organ meats, seafood,
plants (depending upon
soil selenium content)
Sodium 1.5 g -- 2.3 g Processed foods with
added sodium chloride,
salted meats, nuts, cold
cuts
Zinc 11 mg +2 mg ( 18 yrs)
+1 mg (19-30 yrs)
+1 mg (31-50 yrs)
34 mg ( 18 yrs)
40 mg (19-30 yrs)
40 mg (31-50 yrs)
Fortified cereals, red
meat
Sources: See reference citations listed above in the table title.
21
8/23/06
Resources/Web Sites
The Academy of Breastfeeding Medicine (ABM)
http://www.bfmed.org/index.asp
The American Academy of Pediatrics
141 Northwest Point Blvd., Elk Grove Village, IL, 60007
1-847- 434-4000
http://www.aap.org/
Breastfeeding Policy
http://www.aap.org/policy/re9729.html
Breastfeeding Promotion in Pediatric Office Practices Program
1-847-228-5005, extension 4779
http://www.aap.org/breastfeeding/new%20resources.cfm#AAP
Baby-Friendly USA Hospital Initiative
1-508- 888-8092
http://www.babyfriendlyusa.org
Best Start Social Marketing
Web site: www.beststartinc.org/trainings.asp
Breastfeeding Online (Jack Newman, M.D.)
http://www.breastfeedingonline.com/newman.shtml
The Breastfeeding Task Force of Greater Los Angeles
http://www.BreastfeedLA.org
California Department of Public Health
Maternal Child and Adolescent Health Branch
1615 Capitol Avenue
Sacramento, California 95899-7420
1-866-241-0395
http://www.cdph.ca.gov/programs/MCAH/Pages/default.aspx
California Department of Public Health
WIC Supplemental Nutrition Branch
3901 Lennane Drive
Sacramento, California 95834
1-800-852-5770
http://www.wicworks.ca.gov
8/23/06
22
UC Davis Human Lactation Center
Department of Nutrition
University of California
One Shields Avenue
Davis, California 95616
Phone: (530) 754-5364
http://lactation.ucdavis.edu
Human Milk Banking Association of North America
1500 Sunday Drive, Suite 102, Raleigh, NC 27607
1-919-787-5181
http://www.hmbana.org
International Lactation Consultants Association
ILCA 1500 Sunday Drive Suite 102 Raleigh, NC 27607
1-919-861-5577
http://www.ilca.org
Lactation Education Resources
3621 Lido Place
Fairfax, VA 22031
1-703-691-2069
http://www.LERon-line.com
La Leche League International
1400 N. Meacham Rd., Schaumburg, IL 60173-4808
1- 847-519-7730
TTY: 1-847-592-7570
http://www.lalecheleague.org
MyPyramid for Pregnancy and Breastfeeding
http://www.mypyramid.gov/mypyramidmoms/index.html
Wellstart International
P.O. Box 80877
San Diego, CA 92138-0877
Phone: 619-295-5192
http://www.wellstart.org
World Alliance for Breastfeeding Action (WABA)
P.O. Box 1200, 10850 Penang, Malaysia
http://www.waba.org.my/
8/23/06
23
References
1 Bopp M, Lovelady, C, Hunter C, Kinsella T. Maternal diet and exercise: effects
on long-chain polyunsaturated fatty acid concentration in breast milk. Journal of
the American Dietetic Association. 2005;105:1098-1103.
2 US Department of Health and Human Services. Healthy People 2010.
Washington, DC: January 2000. http://www.healthypeople.gov/. Accessed
8/23/06.
3 Data sources: Mothers Survey, Abbott Laboratories, Inc., Ross Products
Division; National Immunization Survey (NIS), CDC, NIP, and NCHS.
4 Lawrence RA and Lawrence RM. Breastfeeding: A guide for the medical
professional. Elsevier Mosby, Philadelphia, 2005.
5 Food and Nutrition Board, Institute of Medicine. Nutrition During Lactation.
National Academy Press, Washington, DC, 1991.
6 Sadurskis A, Kabir N, Wager J, et al. Energy metabolism, body composition
and milk production in healthy Swedish women during lactation. Am J Clin Nutr.
1988;48:44-49.
7 Butte NP, Garza G, Smith EO, et al. Human milk intake and growth in
exclusively breast-fed infants. J Pediatrics. 1984;104:187-195.
8 American Academy of Pediatrics Policy Statement: Breastfeeding and the use
of human milk. Pediatrics. 2005;115(2):496-506.
9 The American Dietetic Association. Position of the American Dietetic
Association: Promoting and supporting breastfeeding. J Am Diet Assoc. 2005;
105:810-818.
10 Labbok MH. Effects of breastfeeding on the mother. The Pediatric Clinics of
North America. 2001;48(1):143-158.
11 Strube, AM, Rich-Edwards, JW, Willett, WC, Manson, JE, Michels, KB.
Duration of lactation and incidence of type 2 diabetes. JAMA. 2005;294:2601-
2610.
12 Riordan J. Breastfeeding and Human Lactation. 3rd Edition. Jones and
Bartlett, Sudbury, MA; 2005.
13 Centers for Disease Control and Prevention. Breastfeeding: Infectious
Diseases and Specific Conditions Affecting Human Milk: Hepatitis B and C
8/23/06
24
Infections. Department of Health and Human Services.
www.cdc.gov/breastfeeding/disease/hepatitis.htm Accessed 9/26/06.
14 California Department of Health Services, Maternal Child and Adolescent
Health Branch. Steps to take program guidelines for enhanced health education,
nutrition and psychosocial services. Sacramento: Education Programs and
Associates; 2005.
15 US Department of Health and Human Services. HHS Blueprint for Action on
Breastfeeding. Washington, DC: US Department of Health and Human Services,
Office on Women's Health; 2000.
16 Newborn Screening Data Base, Genetic Disease Branch, California
17 Brown JE. Nutrition Through the Life Cycle. 2nd ed. Wadsworth, Belmont,
CA: Thomson Learning, Inc., 2005.
18 United States Department of Agriculture. MyPyramid Food Guidance System
Education Framework 2005. Washington, DC.
19 US Department of Agriculture and US Department of Health and Human
Services. Dietary Guidelines for Americans, 6th Edition. Washington, DC:
Government Printing Office, January, 2005.
20 Strode MA, Dewey KG, Lonnerdal B. Effects of short-term caloric restriction
on lactational performance of well-nourished women. Acta Paediatr Scand
1986;75:2229-229.
21 Goldgerg GR, Prentice AM, Coward WA, et al. Longitudinal assessment of
energy expenditure in pregnancy by the doubly labeled water method. Am J Clin
Nutr. 1993;57:494-505.
22 Institute of Medicine. Dietary reference intakes for energy, carbohydrate.
fiber, fat, fatty acids, cholesterol, protein, and amino acids (2002). Washington
DC: The National Academy Press.
23 Picciano, MF. Pregnancy and Lactation: Physiological Adjustments,
Nutritional Requirements and the Role of Dietary Supplements. J Nutr. 2003;
133:1997S-2002S.
24 Butte NF, Garza C, Stuff JE, Smith EO, Nichols BL. Effect of maternal diet
and body composition on lactational performance. Am J Clin Nutr. 1984;39:296-
306.
8/23/06
25
25 Gonzalez-Cossio T, Habicht JP, Rasmussen KM, Delgado HL. Impact of food
supplementation during lactation on infant breast-milk intake and the proportion
of infants exclusively breast-fed. J Nutr. 1998;128(10):1692-1702.
26 Institute of Medicine. Dietary reference intakes for calcium, phosphorous,
magnesium, vitamin D, and fluoride (1997); Dietary reference intakes for thiamin,
riboflavin, niacin, vitamin B
6
, folate, vitamin B
12
, pantothenic acid, biotin and
choline (1998); Dietary reference intakes for vitamin C, vitamin E, selenium, and
carotenoids (2000); and dietary reference intakes for vitamin A, vitamin K,
arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel,
silicon, vanadium, and zinc (2001). Washington DC: The National Academy
Press.
27 Allen LH. Maternal micronutrient malnutrition: effects on breast milk and infant
nutrition, and priorities for intervention. SCN News. 1994;11:21-24.
28 Hale TW. Medications and Mothers Milk. 12th ed. Amarillo, TX: Hale
Publishing, L.P.; 2006.
29 Von Shenck U, Bender-Gtze C, Koletzko B: Persistence of neurological
damage induced by dietary vitamin B12 deficiency in infancy. Arch Dis Child
77:137,1997.
30 Wardinsky TD, Montes RG, Friederich et al. Vitamin B
12
deficiency
associated with low breast-milk vitamin B
12
concentration in an infant following
maternal gastric bypass surgery. Arch Pediatr Adol Med. 1995;149(11):1281-
1284.
31 Renault F, Verstichel P, Ploussard JP et al. Neuropathy in two cobalamin-
deficient breast-fed infants of vegetarian mothers. Muscle Nerve.
1999;22(2):252-254.
32 Picciano MF. Nutrient composition of human milk. Pediatric Clinics of North
America. 2001;48(1): 53-65.
33 Mackey AD, Picciano MF: Maternal folate status during extended lactation
and the effect of supplemental folic acid. Am J Clin Nutr. 1999;69:285.
34 Delange F: The role of iodine in brain development. Proc Nutr Soc. 2000;
59:75.
35 Institute of Medicine. Dietary reference intakes for energy, carbohydrate,
fiber, fat, fatty acids, cholesterol, protein and amino acids. Washington DC: The
National Academy Press; 2002.
8/23/06
26
36 Rosen JM, Rodgers JR, Couch CH, et al. Multihormonal regulation of milk
protein gene expression. Ann NY Acad Sci. 1986;478:63-76.
37 Connor WE, Lowensohn R, Hatcher L. Increased docosahexaenoic acid
levels in human newborn infants by administration of sardines and fish oil during
pregnancy. Lipids. 1996;31(Suppl):S183-S187.
38 Insull W, Ahrens EH. The fatty acids of human milk from mothers on diets
taken ad libitum. Biochemistry Journal. 1959;72:27.
39 Centers for Disease Control and Prevention. Folic Acid: PHS
Recommendations. http://www.cdc.gov/ncbddd/folicacid/health_recomm.htm.
Department of Health and Human Services. Accessed 7/25/2006.
40 Corwin EJ, Murray-Kolb LE, Beard IL. Low hemoglobin level is a risk factor
for postpartum depression. J Nutr. 2003;133:4139-4142.
41 Butte NF, Hopkinson JM. Body composition changes during lactation are
highly variable among women. J Nutr. 1998;128(2S):S381-S385.
42 Dusdieker LB, Hemingway FL, Stumbo PJ. Is milk production impaired by
dieting during lactation? Am J Clin Nutr. 1994;59(4):833-840.
43 Lovelady, CA, Stephenson, KG, Kuppler, KM, Williams, JP. The effects of
dieting on food and nutrient intake of lactating women. J Am Diet Assoc. 2006;
106;908-912.
44 The American Dietetic Association. Position of the American Dietetic
Association and Dietitians in Canada: Vegetarian diets. J Am Diet Assoc.
2003;103(6):748-765.
45 Lovelady CA, Lonnerdal B, Dewey KG. Lactation performance of exercising
women. Am J Clin Nutr. 1990;52(1):103-109.
46 Dewey KG, McCrory MA. Effects of dieting and physical activity on
pregnancy and lactation. Am J Clin Nutr. 1994;59 (2 suppl):446S-452S;
discussion: 452S-453S.
47 Nehlig A, Debry G. Consequences on the newborn of chronic maternal
consumption of coffee during gestation and lactation: a review. J Am Coll Nutr.
1994;13(1):6-21.
48 La Leche League International. Frequently asked questions on caffeine and
breastfeeding. www.lalecheleague.org/FAQ/Caffeine.html.
8/23/06
27
49 Schulte P. Minimizing alcohol exposure of the breastfeeding infant. J Hum
Lact. 1995;11(4): 317-9.
50 Mennella JA, Gerrish CJ. Effects of exposure to alcohol in mothers milk on
infant sleep. Pediatrics. 1998;101(5):E2.
51 Vio F, Salazar G, Infante C. Smoking during pregnancy and lactation and its
effects on breast milk volume. Am J Clin Nutr. 1991;54:1011.
52 Schulte-Hobein B, Schwartz-Bickenbach D, Abt S et al. Cigarette smoke
exposure and development of infants throughout the first year of life: Influence of
passive smoking and nursing on cotinine levels in breast milk and infants urine.
Acta Paediatr Scand. 1992;81:550.
53 Dahlstrom A, Lundell B, Curvall M, et al. Nicotine and cotinine concentrations
in the nursing mother and her infant. Acta Paediatr Scand. 1990;79:142.
54 AAP Committee on Drugs, American Academy of Pediatrics. The transfer of
drugs and other chemicals into human milk. Pediatrics. 1994;93:137.
55 Kopec K. Herbal medications and breast-feeding. J Hum Lact. 1999;15(2):
157-161.
56 Astley SJ, and Little RE. Maternal marijuana use during lactation and infant
development at one year. Neurotoxicol Teratol. 1990;122(2);161-8.
8/23/06
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