Transcript Breastfeeding: Maternal diet and lifestyle

Breastfeeding: Maternal diet and
lifestyle
Breastfeeding: Maternal diet and
lifestyle
• Maternal nutrient
needs for successful
lactation
• Impact of maternal
diet on milk
composition
• Can infant health
outcomes be
influenced by
manipulating the deit
of lactating women?
Breastfeeding: Maternal diet and
lifestyle
• Lifestyle issues
– Supportive of
sustained lactation
– Impacting milk
production and
compostion
– Health and safety
issues
• Drug exposure
• Environment
contaminants
• other
How is milk made?
Milk Synthesis
• Mammary gland contains stem cells and
highly differentiated secretory alveolar
cells at the terminal ducts. Stimulated by
insulin and HGH synergized by prolactin,
these cells are active in milk synthesis and
secretion
Milk Synthesis and secretion
• Under neuroendocrine control that varies with timing and
stage of lactation
– Prolactin
– Lactogens
– Estrogen
– Thyroxine
– Growth hormone
– ACTH
– other
– Stimulus: infant suckling
Milk synthesis and sectretion
• Exocytosis (protein, lactose, Ca/Ph, citrate)
• Fat synthesis (TG synthesized in cytoplasm and
smooth endoplasmic reticulum + precursors imported
from maternal circulation): alveolar cells syntesize SCFA
• Secretion of ions and water
• Immunoglobins transferred from
extracellular spaces
Milk synthesis
• Protein: vast majority of proteins present in
human milk are specific to mammary
secretions and not identified in any
quantitiy elsewhere in nature:
– Immunoglobins transferred from plasma in
early stages of lactation
– De novo protein synthesis by mammary gland
Paracellular Pathway (5th process)
• The paracellular spaces between alveolar
cells normally prevent transfer secondary
to tight junctions. If these spaces become
“leaky” plasma constituents may pass
directly into the milk.
• Association of maternal diet with milk composition?
– Volume
– Nutrient composition
• Can diet alter nutrient composition of
maternal milk?
* in general milk composition maintained to
meet infant needs.
* water soluble vitamins
* fat/fatty acids
Science and Lactation: Frank Hytten
• “ In general, it is probable that the breast
has a high priority for nutrients and that
moderate maternal undernutrition will have
little effect on milk production. But severe
malnutrition, which rarely exists without
associated ill-health and other adverse
circumstances, may reduce milk yield”
Diet, milk production, and milk composition
• There is a great variation in milk composition
during a feed, from feed to feed, and even
between breasts.
• The impact of dietary variation and milk
composition is unclear. Overall milk composition
remains relatively unaffected by diet variations
although there are reports to the contrary:
– DHA and ARA supplementation, vegan diet, drugs
and environmental contaminants,…..
Influence of diet on milk
composition
• Protein-energy malnutrition impacts milk volume.
Composition remains relatively unaffected
• Water soluble vitamins move readily from serum
to milk thus dietary fluctuations are more
apparent
– B12 vegan, case report of beri-beri…..
• Fat soluble vitamin content not improved with
supplementation
• Fatty acid composition (DHA and ARA) altered
by maternal diet and supplementation
Breast milk composition and Diet
• DHA levels of breastmilk vary with diet. Increased
amounts of DHA have been found in the breaskmilk of
mothers consuming fish or fish oil, and with
suppleemntation.
• Water soluble vitamins may vary with diet. Diets
inadequate in B12 or thiamin have been associated with
case reports of deficiency in infants. High intakes of
Vitamin C, however, does not apear to change the
content of breastmilk.
• Supplementation of fat soluble vitamins do not appear to
alter the content of breastmilk
• Iron supplementation does not appear to alter the iron
content of breastmilk
Questions regarding Breast milk
composition and Diet
Maternal deficiencies and infant health
Infant health vs maternal health
Treatment of specific conditions or “supermilk”
through dietary modification
Nutrient Needs
• Increased Needs?
• Replace maternal
losses to milk?
• Increased energy
needs---- increase
in specific vitamins (ie
B vitamins)
• Association of
maternal diet with
milk composition?
Energy
• Estimate need to
produce 850 ml/day
• 600 kcal/d
• 80% efficiency
• 750 kcal/day
• Fat stores of
pregnancy may
provide 1/3
• + 500 kcal above
non lactating
women
Energy
• Does a breastfeeding woman need to consume more
energy to sustain lactation?
– Energy deficits may not impact milk volume
– ? Estimating energy cost
– Variety of ways to meet energy needs
• Increased consumption
• Decreased expenditure
• Mobilization of stores
Calcium
• Calcium intake has
little impact on
calcium content of
breastmilk
• ? Is there an impact
on maternal calcium
status and bone
density
Calcium
• Calcium is mobilized from bone to
maintain milk content during lactation
• Phenomena of bone loss and recovery
during lactation and after weaning has
been documented by several researches
(Cross, Kalkwark, Specker) and may
represent normal physiology
• ? Consequences of inadequate intake on
long term maternal bone health
DRI
Nutrient
Female
Pregnancy
Lactation
Protein g/d
38
50
Calcium
mg/d
1000 - 1300
1000 - 1300
1000 - 1300
Phosphorus
mg/d
1055 - 580
1055 - 580
1055 - 580
Zinc mg/d
6.8 - 7.3
9.5 - 10.5
10.4 - 10.9
Iron mg/d
7.9 - 8.1
22 - 23
6.5 - 7
Copper ug/d
685 - 700
785 - 800
985 - 1000
Iodine
95
160
209
60
DRI
nutrient
Female
Pregnancy
Lactation
14-18
19-50
14-18
19-50
14-18
19-50
A
700
700
750
770
1200
1300
C
65
75
80
85
115
120
E
15
15
15
15
19
19
DRI
nutrient
Female
Pregnancy
Lactation
14-18
19-50
14-18
19-50
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
NAS Food and Nutrition Board
1992
• Healthful diet based on DRI/RDA
• Avoid or drastically reduce the use of potentially
harmful substances
• Take enough fluids to keep from getting thirsty
• At least 1800 kcal/d to maintain milk production
• Limit intake of coffee, cola or other caffeine
sources to 2 servings or less per day
• Avoid alcoholic beverages
• Cultural/religious customs
• Vegan/vegetarian diets
• dieting
Frequently seen advise to
breastfeeding women
• Eat to hunger
• Drink to thirst
• Don’t worry
Modification of infant health
through maternal diet
• DHA
• Allergy
• Colic
Allergies: Breastmilk
• May be protective due to sIgA and
mucosal growth factors
• Maternal avoidance diets in lactation
remain speculative. May be useful for
some highly motivated families with
attention to maternal nutrient adequacy.
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 acidbased formula) as an alternative to breastfeeding.
Colic and maternal diet
• David Hill et al Effect of
Low allergen Maternal
Diet on Colic among
breastfed Infants: A
Randomized controlled
Trial, Pediatrics Vol 116
#5 Nov 2005 709-15
David Hill et al
• N107 infants
<6weeks of age with
colic defined by
elevated Cry/Fuss
Score.
• Study Group: 53, 680
minutes/48 hours
• Control: 54, 631
minutes/48 hours
Hill et al
• Study: Low allergen.
• Control: Diet as usual.
Maternal elimination
• 43 completed
of cows milk, peanuts,
treenuts, wheat, soy,
and fish.
• 47 completed
Hill et al
• Study Group
– Reduction in cry score
by 25% (35 of 47)
– 30/47 still had colic as
defined by cry/fuss
scores >360 min/48
hours
• Control Group
– Reduction of cry score
by 25% (16 of 43)
– 31/43 still had colic as
defined by cry/fuss
score > 360 min/48
hours
• Authors Conclusion: Exclusion of
allergenic foods from maternal diet was
associated with a reduction in distressed
behavior among breast fed infants <6
weeks of age.
What advise?
Weighing Risks and Benefits
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Diet restrictions
Diet supplements
Allergens
other
Drugs and Environmental
Contaminants
Drugs and Human Milk
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Maternal considerations
Drug Characteristics
Concentration in milk
Volume of milk consumed
Infant Characteristics
Maternal considerations
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Route
Dose
Duration
? Treatment
? alternative
Drug Characteristics
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Size of molecule
Solubility in lipids and water
Protein binding capability
Drug pH
Diffusion rates
Half life
Metabolites
Drug Characteristics
• Drugs transferred by: simple diffusion,
carrier mediated, active transfer,
pinocytosis, reverse pinocytosis.
• Transfer and solubility gradient
• Concentration in milk X amount milk
consumed = potential dose infant exposed
to
Infant Characteristics
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? Absorption from infant gut
? Infant metabolism
Can infant detoxify and excrete?
Will amounts accumulate
What doses/ levels are safe?
Infant
• Is this a drug normally given to an infant?
– Amount, side-effects, safe dose and level
known.
• Is this a drug not usually given to infant?
– More difficult question, is safety known, is
there any evidence or data to make a
decision, is there fetal or animal data on
safety?
AAP statement on Drugs and
Human Milk
• Pediatrics 2001 108(3) 776-788
• 7 tables
– 1) cytotoxic drugs that may interfere with infant metabolism
– 2) drugs of abuse for which adverse effects on infants have been
reported
– 3) radioactive drugs requiring temporary cessation of nursing
– 4) drugs with unknown effects
– 5) drugs with some associated effects that should be used with
caution
– 6) medications compatible with nursing
– 7) food and environmental agents that may have effects on
breastfeeding
NAS Food and Nutrition board
1992
• Environmental contaminants:
– Heavy metals e.g. mercury
– Organic chemicals e.g. pesticides
• DDT, PCB’s
Drug use and Pregnancy
• Drugs contraindicated
• Should be avoided if there are alternatives
• No known risk
AAP: Breastfeeding and Smoking
• 1994: Nicotine placed in Contraindicated secondary to
decrease in milk production, decrease weight gain in
infant, and increase in respiratory illness etc.
• ? Breastfeeding and smoking vs bottle feeding and
smoking…..protection against respiratory illness
• 2001: In the interest of supporting breastfeeding,
Nicotine was removed from the previous Table.
• Advise against smoking. Provide support for smoking
cessation.
• Smoking: nicotine exposure, carbon
monoxide, risk of 2nd hand smoke, burns
AAP: Drugs of abuse for which
adverse effects have been reported
• Amphetamine: irritability, poor sleeping pattern
• Cocaine: cocaine intoxication, irritability,
vomiting, diarrhea, tremulousness, seizures
• Heroin: tremors, restlessness, vomiting, poor
feeding
• Marijuana: only one report in literature, no effect
mentioned, very long half life for metabolites
(see animal studies)
• Marijuana: animal studies show structural
changes in brain cells of newborns
exposed to cannabis through maternal
milk, impaired RNA/DNA formation. Infant
would be exposed through milk and
environment
AAP: Alcohol
• With large amounts, drowsiness,
diaphoresis, deep sleep, weakness,
decrease in linear growth, abnormal
weight gain, maternal ingestion of 1g/kg
daily decreases milk ejection reflex.
Alcohol
• Compatible with breastfeeding but use
caution/moderation.
Caffeine
• Irritability, poor sleeping pattern, excreted
slowly, no effect with moderate intake of
caffienated beverages (2-3 cups per day)
• General advise, use moderation.
Drugs and Lactation
• Thomas Hale Medications and Mother’s
Milk 11th edition 2004 Pharmasoft
Publishing L.P., Texas
http://www.iBreastfeeding.com
• Gerald G. Brigs et al Drugs in Pregnancy
and Lactation 7th edition 2005 Lippincott
Williams and Wilkins
What Advise would you give?
• Maternal diet and
health?
• Diet modification for
infants health?
– DHA, Vitamin
Supplements,
elimination diets
What advice would you give?
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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?”