بسم الله الرحمن الرحیم

بسم الله الرحمن الرحیم

INTRODUCTION:

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.

Key Message: Making Milk is Easy

Moms body is built for lactation

Efficient nutrient utilization

Diet, fluid intake only minimally important

“Stress” only minimally important

Most women only use 2/3 of capacity!

Baby takes about 2/3 of milk available

Most who can gestate – can lactate

Table 1: Key Recommendations for Breastfeeding Women from the Dietary Guidelines for Americans 200519

Weight Reduction Moderate weight reduction is safe and does not compromise weight gain of the nursing infant.

Physical Activity Neither acute nor regular exercise adversely affects the mother's ability to

successfully breastfeed .

Nutrient needs during lactation are a function of the woman’s 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.

What's New? Exercise during lactation will not only improve the mother’s cardio

respiratory fitness but may increase the amount of essential fatty acids in her breast milk.

California Food Guide Maternal Nutrition During LactationChapter 8: Maternal Nutrition During Lactation

Postpartum Weight LossPostpartum Weight Loss:

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.

Nutrition and LactationNutrition and LactationWhich aspects of diet are particularly important for women who are

breast-feeding? It has been calculated that breast-feeding carries a daily energy

cost of 650 kcal. However, some of this is obtained by using up fat stored during

pregnancy for this purpose. Consequently, women who exclusively breast-feed for 3–4

months need an extra 500 kcal/day, on average, which corresponds to an average milk output of 750 ml/day.

Assuming that this extra energy is obtained via consumption of a balanced and varied diet, the additional needs for essential vitamins and minerals will also be met.

Additional requirements for calcium are particularly high

• Obese and overweight may not need entire to add the extra calories

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

Nutrition during lactationLactating mother’s produce normally about 700-800 g of milk daily

Protein requirement

100g milk contains ~1.3 g (first month) and

~1.2 g (during lactation) protein

to produce 100 g milk-the need for extra protein is 2,4 g

The increment of protein allowance:

20 g/day for the first 6 month of full lactation

To prevent dehydratation: at least 2-3 litre water is also need each day for milk production

Energy requirement: ~500 additional calories but about 150 kcal is supplied by extra fat, accumulated during pregnancy

Keep in mind!

In menu planning guidelines: fluids, dairy products, fruits and vegetables are emphasized

some helpful nutritional guidelines:

Calcium:• Calcium is very important to everyone but especially when pregnant or breastfeeding because studies have shown that calcium is drawn out of your bones during pregnancy and lactation.

•The recommended daily allowance is 1,600mg daily; which is 2-4 servings of milk products.

• Some good sources of calcium include yogurt, milk, cheese, broccoli, watercress, oranges, almonds, tofu and dark leafy greens.

Iron: Iron is important during pregnancy and postpartum. A lack of iron in your blood can cause you to feel weak, light headed, tired, have a loss of appetite, or be more likely to get colds and flu.

Continuing to take your prenatal vitamins will help keep your iron levels up but the best way to have enough iron in your blood is to eat foods that are high in iron.

Here is a list of foods- red meat, lamb, turkey, chicken, pork and fish, kidney beans, dried beans and peas, whole grain breads and iron fortified cereals, greens, broccoli, baked potato with skin, raisins, and dried fruit.*** High vitamin C foods/beverages along with high iron foods help your body absorb iron easier, so drink a glass of 100% fruit juice with your meal.

Folic Acid: Folic acid is very important if you could potentially become pregnant. Folic acid is a B-vitamin, when taken one month before conception and throughout the first trimester reduces the risk of neural tube defects.

The recommended amount of folic acid is 400 micrograms daily which can be consumed in a vitamin supplement or by eating foods high in folic acid.

Breakfast cereal are especially high in folic acid, many contain 100% of the daily value, enriched pasta, rice, breads, flour and other grains have been fortified with folic acid. Fruits, green leafy vegetables, dried beans and legumes also contain folic acid.

Vitamins: It is recommended that breastfeeding women continue to take prenatal vitamins. Eating lots of fruits and vegetables will also help you get all the vitamins and mineral you need. Vitamin D is important to your baby's bone growth. It is now recommended that ALL infants and children have a minimum daily intake of 400 IU of Vitamin D beginning soon after birth. Discuss questions and concerns about Vitamin D with your baby's doctor. Vitamin D is found in fish, milk, eggs and butter.

Caffeine: Caffeine should be limited to 2 servings or less daily. Caffeine is found in coffee, soft drinks, tea, some medications and chocolate. If your baby seems unusually fussy or wakeful you may want assess how much caffeine you are consuming.

•© 2004 American Society for Clinical NutritionVitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant1,2,3,4

•Bruce W Hollis and •Carol L Wagner+ Author Affiliations•1From the Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC.

We conclude that the current DRI of 400 IU/d vitamin D for lactating mothers is irrelevant to the vitamin D nutritional status of mothers and nursing infants. Maternal vitamin D intakes of ≥4000 IU/d appear to be safe and to provide sufficient vitamin D to ensure adequate nutritional vitamin D status for both mothers and nursing infants. Additional detailed studies will be required to determine the optimal vitamin D supplementation regimen for lactating women

My Pyramid Education Framework provide a basis for My Pyramid Education Framework provide a basis for dietary guidance for healthy individuals:dietary guidance for healthy individuals:18 18

(1) Variety—Eat foods from all food groups and subgroups.

(2) Proportionality—Eat 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) Moderation—Choose forms of foods that limit intake of saturated or trans fats, added sugars, cholesterol, salt, and alcohol.

(4) Activity—Be physically active every day.

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, ½ cup cooked cereal, rice, pasta 1 roll, pancake, small tortilla ½ bagel

Vegetables 3½ 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, 2½ cups orange veggies, 3½ cups legumes, 7 cups starchy veggies, and 8½ cups of other veggies

Fruits2 cups Choose fresh, frozen, canned fruit or 100% juice. Medium whole fruit= ½ cup ½ cup dried fruit= 1 cup fresh fruit

Table 2: Daily Food Choices for Lactating Women18, 19 (2200-2800 calories)*

Food Groups

Recommended # of Servings

Serving Sizes and Food Choices

Milk3-4* of these choices *4 for teens

1 cup low-fat or fat-free milk or yogurt 1 ½ ounces cheese 2 ounces of low-fat cheese 1 cup pudding or custard made with milk 1 ½ 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 ½ cup cottage cheese ¼ cup cooked dry beans, peas, lentils ¼ cup tofu 1 Tablespoon of peanut butter ½ ounce nuts or seeds

Oils6-8 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

Table 2: Daily Food Choices for Lactating Women18, 19 (2200-2800 calories)*

Fluids:Drinking plenty of fluids is very important when breastfeeding. Eight to ten glasses of fluids are recommended daily.

Drink when you feel thirsty.

Water, 100% juice and low fat milk are good fluids to keep on hand.

Try to always have some water available when you are breastfeeding.

Snacks: One of the biggest problems mothers face when they have a new baby is finding time for themselves.

Make it a priority to take care of your self and find time to eat. It is not only important for you but also for your baby.

Supplement and Herbs: The FDA does not regulate supplements and herbs and therefore are not recommended when breastfeeding without consulting your health care provider.

Artificial Sweeteners:

There is not evidence that artificial sweeteners are harmful when breastfeeding.

Of course there is one exception to this rule for mothers of infants with Phenylketonuria (PKU) as aspartame contains phenylalanine. In general it is always a good idea to keep food additives to a minimum.

Breast milk composition and Diet• DHA levels of breast milk vary with diet. Increased amounts of

DHA have been found in the breast milk of mothers consuming fish or fish oil, and with supplementation.

• 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 appear to change the content of breast milk.

• Supplementation of fat soluble vitamins do not appear to alter the content of breast milk

• Iron supplementation does not appear to alter the iron content of breast milk

Association of maternal diet with milk composition?

– Volume

– Nutrient composition

• Can diet alter nutrient composition of

maternal milk?

o in general milk composition

maintained to meet infant needs.

o water soluble vitamins

o fat/fatty acids

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 EPA 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

Some breast-feeding women say that avoiding spicy or gassy foods, such as onions or cabbage, can help — but this hasn't been proved through research.

Also, you might try eliminating or reducing the amount of caffeine in your diet.

For help determining links between your diet and your baby's behavior, you might keep a food diary. List everything you eat and drink, along with notes about how your baby seems to react — if at all.

If removing a certain food or drink from your diet has no impact on your baby's fussiness, add it back to your diet and consider other possible culprits instead. If you're concerned about your baby's behavior, consult your baby's doctor.

Remember, there's no need to go on a special diet while you're breast-feeding. Simply focus on making healthy choices — and you and your baby will reap the rewards.

To boost milk production: Breast-feed as soon as possible. Waiting too long to start breast-feeding can contribute to a low milk supply. Hold your baby skin to skin right after birth and your baby will likely breast-feed within the first hour after delivery.

Breast-feed often. For the first few weeks, breast-feed your baby at least every two to three hours round-the-clock. Breast-feeding less often can contribute to a low milk supply.

Be alert to feeding problems. It's OK for your baby to nurse on only one breast at a feeding — but if this happens regularly, your milk supply will decrease. Pump the other breast to relieve pressure and protect your milk supply until your baby begins taking more at each feeding.

Infant suckles at the breast.

Stimulation ofnerve endings

in mother’snipple/areola sends signalto mother’s

hypothalamus/pituitary.

Pituitary releases prolactin and oxytocin.

Hormones travel via bloodstream

to mammary gland to stimulate milk

production and milk ejection

reflex (let-down).

Copyright © 2003, Rev 2005 American Academy of Pediatrics

Foods to avoid when breastfeeding: There are no specific foods you should avoid when breastfeeding. If you notice your baby is fussy often you may want to consider what you ate 4-6 hours previously.

Some foods that babies can be sensitive to are cabbage, beans, broccoli and some times peanuts, cow's milk, eggs, wheat, fish, citrus foods and other nuts if there is a strong family history of allergies to these foods.

Drugs in Human Milk: Some medications (prescription and over-the-counter medications, and all street drugs) will pass into the mother's milk.

Breastfeeding mothers should check with their Lactation Consultant and Physicians before taking any medications

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.

• 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.

AAP: Breast milk and allergy

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

• 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.

Colic and maternal diet• David Hill et al Effect of Low

allergen Maternal Diet on Colic among breastfed Infants: A Randomized controlled Trial, Pediatrics Vol 116 #5 Nov 2005 709-15

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