the composition of breast milk: does maternal diet matter?

The Composition of Breast Milk: Does The Composition of Breast Milk: Does Maternal Diet Matter?Maternal Diet Matter?

Michael K. Georgieff, M.D.Michael K. Georgieff, M.D.

Professor of Pediatrics and Child DevelopmentProfessor of Pediatrics and Child Development

Director, Center for Neurobehavioral DevelopmentDirector, Center for Neurobehavioral Development

University of MinnesotaUniversity of Minnesota

OverviewOverview

Role of Breast Milk in Infant NutritionRole of Breast Milk in Infant Nutrition Classes of NutrientsClasses of Nutrients Mechanisms of Maternal->Milk TransportMechanisms of Maternal->Milk Transport Milk VolumeMilk Volume MacronutrientsMacronutrients

– Transport; IOM RecommendationsTransport; IOM Recommendations

Selected MicronutrientsSelected Micronutrients– Transport; IOM RecommendationsTransport; IOM Recommendations

VitaminsVitamins– Transport; IOM RecommendationsTransport; IOM Recommendations

Role of Breast Milk in Infant NutritionRole of Breast Milk in Infant Nutrition

Human Breast Milk is the Gold Standard for Human Breast Milk is the Gold Standard for human nutritionhuman nutrition

Usually, complete nutrition for first 6 months in Usually, complete nutrition for first 6 months in term infantsterm infants

– Vitamin DVitamin D

– IronIron

Preferred base for feeding preterm infantsPreferred base for feeding preterm infants– Reduction of NEC ratesReduction of NEC rates

– Needs fortificationNeeds fortification

Classes of NutrientsClasses of Nutrients

Water (volume)Water (volume) MacronutrientsMacronutrients

– CarbohydrateCarbohydrate

– FatFat» LC-PUFAsLC-PUFAs

MineralsMinerals– Sodium, Potassium, Chloride, CalciumSodium, Potassium, Chloride, Calcium

Selected MicronutrientsSelected Micronutrients– Iron, Zinc, CopperIron, Zinc, Copper

VitaminsVitamins– Water Soluble (C, Bs, Folate)Water Soluble (C, Bs, Folate)

– Fat Soluble (A,E,D,K)Fat Soluble (A,E,D,K)

Mechanisms of Maternal Milk ProductionMechanisms of Maternal Milk Production

Nutrients transported across single cell layer from maternal Nutrients transported across single cell layer from maternal serum into milkserum into milk

– Mammary Epithelial CellMammary Epithelial Cell

Transport can be passive or active based onTransport can be passive or active based on– NutrientNutrient

– Developmental time periodDevelopmental time period

Active transporters similar to those found at other single cell Active transporters similar to those found at other single cell transport surfacestransport surfaces

– Placenta, intestine, blood-brain barrierPlacenta, intestine, blood-brain barrier

– Typically involve Typically involve

» Transporter from maternal serum into MEC (apical)Transporter from maternal serum into MEC (apical)

» Exporter from MEC to milk (basal)Exporter from MEC to milk (basal)

The Mammary Epithelial Cell

Water (Volume)Water (Volume)

Water (Milk Volume)Water (Milk Volume)

Water is a nutrient!Water is a nutrient!– Important for metabolic processingImportant for metabolic processing

– Consumed and produced by numerous enzymatic processesConsumed and produced by numerous enzymatic processes

Low milk volume a common cause of lactation failureLow milk volume a common cause of lactation failure– Premature deliveryPremature delivery

– Intrauterine growth-retardation (maternal hypertension)Intrauterine growth-retardation (maternal hypertension)

Milk volume not a function of maternal hydration Milk volume not a function of maternal hydration (within reason)(within reason)

– Drinking more water doesn’t helpDrinking more water doesn’t help

Milk volume is a function of amount of lactose Milk volume is a function of amount of lactose secreted by MECsecreted by MEC

Water (Milk Volume)Water (Milk Volume)

Mammary epithelial cell assembles and secretes Mammary epithelial cell assembles and secretes lactoselactose

Water (milk volume) follows osmoticallyWater (milk volume) follows osmotically Strategies to increase lactose production and Strategies to increase lactose production and

secretion lead to increased milk volumesecretion lead to increased milk volume– Growth hormone administrationGrowth hormone administration

– Diet manipulations (increased CHO intake)Diet manipulations (increased CHO intake)» Does not work in non-fasting stateDoes not work in non-fasting state

– Genetic variability (polymorphisms of CHO metabolism)Genetic variability (polymorphisms of CHO metabolism)

MacronutrientsMacronutrients

CarbohydratesCarbohydrates

FatFat

Macronutrients: CarbohydratesMacronutrients: Carbohydrates

Current recommendation is for an additional 400 Kcal/day for lactating Current recommendation is for an additional 400 Kcal/day for lactating mothersmothers

– No recommendation re: carbohydrate/fat ratioNo recommendation re: carbohydrate/fat ratio

Lactose is the primary carbohydrate in mother’s milkLactose is the primary carbohydrate in mother’s milk Dietary lactose is broken down by intestinal lactase into glucose and Dietary lactose is broken down by intestinal lactase into glucose and

galactosegalactose– No circulating lactose in mother’s bloodNo circulating lactose in mother’s blood

Milk lactose must be synthesized from serum glucose and galactoseMilk lactose must be synthesized from serum glucose and galactose– ““Hexoneogenesis” Hexoneogenesis” (Sunehag et al, 2002, 2003)(Sunehag et al, 2002, 2003)

– Source of glucose and galactose are serum glucose, glycerol and dietary Source of glucose and galactose are serum glucose, glycerol and dietary galactosegalactose

Macronutrients: CarbohydratesMacronutrients: Carbohydrates

In fed (non-fasting state), 98% of glucose and 68% of galactose that In fed (non-fasting state), 98% of glucose and 68% of galactose that ends up as lactose in milk is derived from plasma glucoseends up as lactose in milk is derived from plasma glucose

After 24 hour fast, percentages derived from plasma glucose drop to After 24 hour fast, percentages derived from plasma glucose drop to 72% and 51% respectively72% and 51% respectively

– Mammary cells use glycerol as source of carbon moleculesMammary cells use glycerol as source of carbon molecules

Dietary galactose contributes 7 and 12% respectively if provided.Dietary galactose contributes 7 and 12% respectively if provided.

Conclusion: Dietary state and CHO intake matters, but unclear if it Conclusion: Dietary state and CHO intake matters, but unclear if it matters much in fed state. Adaptations appear important for matters much in fed state. Adaptations appear important for survivalsurvival

Sunehag et al, 2002,2003Sunehag et al, 2002,2003

Macronutrients: FatMacronutrients: Fat

Fat is main source of calories in human milk (@55%)Fat is main source of calories in human milk (@55%)– Rat milk is low fatRat milk is low fat– Seal milk is up to 95% fat calories!Seal milk is up to 95% fat calories!

Fat content varies considerably Fat content varies considerably (Koletzko et al, 1992)(Koletzko et al, 1992)

– Between women of different cultures/dietsBetween women of different cultures/diets» Chinese (hi CHO, low fat) < Swedish (hi fat, low CHO)Chinese (hi CHO, low fat) < Swedish (hi fat, low CHO)

– Between women of same culture/dietBetween women of same culture/diet» Urban < Rural South African WomenUrban < Rural South African Women

– Within women over timeWithin women over time No specific IOM recommendations for fat amount or fat No specific IOM recommendations for fat amount or fat

source during lactationsource during lactation

Macronutrients: FatMacronutrients: Fat

Fats are assembled and transported into milk fat globulesFats are assembled and transported into milk fat globules Fat quantity and quality in diet does influence milk fat contentFat quantity and quality in diet does influence milk fat content

– Low fat diet causes MEC to synthesize more fat (6x)Low fat diet causes MEC to synthesize more fat (6x)» Mostly C10, C12 and C14 speciesMostly C10, C12 and C14 species

– DHA supplementation increases DHA content of milkDHA supplementation increases DHA content of milk Fat Source does influence milk fat concentrationFat Source does influence milk fat concentration

– Animal source vs vegetable source dietary fatAnimal source vs vegetable source dietary fat

– Role of trans fatty acids (TFAs) and conjugated linoleic Role of trans fatty acids (TFAs) and conjugated linoleic acid (CLAs)acid (CLAs)

Macronutrients: Effect of Dietary Fat ContentMacronutrients: Effect of Dietary Fat Content

Partially hydrogenated vegetable oil (high TFAs) found Partially hydrogenated vegetable oil (high TFAs) found in processed foods (some margarines)in processed foods (some margarines)

McGuire fed one of three diets to lactating mothers; McGuire fed one of three diets to lactating mothers; measured fat content of milkmeasured fat content of milk

– High PHVO margarine, low PHVO margarine or low High PHVO margarine, low PHVO margarine or low PHVO butterPHVO butter

– In obese women, diet made no differenceIn obese women, diet made no difference– In lean women, diet made large differenceIn lean women, diet made large difference

» Mothers fed high PHVO margarine made 2% milkMothers fed high PHVO margarine made 2% milk» Mothers fed butter or low PHVO margarine made 3.5% Mothers fed butter or low PHVO margarine made 3.5%

milk (essentially whole milk)milk (essentially whole milk)

Macronutrients: Specific FatsMacronutrients: Specific Fats

Long Chain Polyunsaturated Fatty AcidsLong Chain Polyunsaturated Fatty Acids

– Docosohexanoic Acid (DHA) production is rate limited in neonatesDocosohexanoic Acid (DHA) production is rate limited in neonates

– Essential fatty acids for preterm and probably term infantsEssential fatty acids for preterm and probably term infants

– Necessary for cell membranes in all organsNecessary for cell membranes in all organs

– Important for visual system and brain developmentImportant for visual system and brain development

– TransportedTransported» Across placentaAcross placenta

» Into human milkInto human milk

» Assures constant flow of LC-PUFA to young humanAssures constant flow of LC-PUFA to young human

Influence of Country of Origin on Milk DHA Influence of Country of Origin on Milk DHA (Innis et al, 1992)(Innis et al, 1992)

Country/CultureCountry/Culture % Milk fat as DHA% Milk fat as DHA

Inuit EskimoInuit Eskimo 1.41.4

DominicaDominica 0.90.9

MalaysiaMalaysia 0.90.9

St. LuciaSt. Lucia 0.70.7

Canada/VancouverCanada/Vancouver 0.40.4

AustraliaAustralia 0.350.35

SwedenSweden 0.300.30

USAUSA 0.250.25

GermanyGermany 0.20.2

Maternal Diet Influences Maternal Diet Influences LC-PUFA Content of Human MilkLC-PUFA Content of Human Milk

DHA supplementation to late gestation and lactating DHA supplementation to late gestation and lactating women workswomen works

Boris et al (2004) fed mothers high DHA fish oil or low Boris et al (2004) fed mothers high DHA fish oil or low DHA olive oilDHA olive oil

– Milk content of DHA in fish oil supplemented women at 4, 16 and Milk content of DHA in fish oil supplemented women at 4, 16 and 30 days was 2.3, 4.1 and 3.3 times higher than olive oil 30 days was 2.3, 4.1 and 3.3 times higher than olive oil supplementedsupplemented

Henderson et al (1992) supplemented lactating women Henderson et al (1992) supplemented lactating women with 6 g/d of fish oil for 21 dayswith 6 g/d of fish oil for 21 days

– Milk DHA increased from 0.37% to 0.70% of total fat (by weight)Milk DHA increased from 0.37% to 0.70% of total fat (by weight)

MineralsMinerals

SodiumSodium

PotassiumPotassium

ChlorideChloride

CalciumCalcium

MineralsMinerals

Major minerals are sodium, potassium, chlorideMajor minerals are sodium, potassium, chloride Determined largely by osmotic forces (milk Determined largely by osmotic forces (milk

volume)volume)– Active Na and K pumpsActive Na and K pumps

Na, K, Cl are determined by electrical gradient in Na, K, Cl are determined by electrical gradient in secretory cells and not affected by maternal dietsecretory cells and not affected by maternal diet

No specific IOM recommendations for these No specific IOM recommendations for these mineralsminerals

CalciumCalcium

Calcium transported actively, but Calcium transported actively, but mechanisms are poorly understoodmechanisms are poorly understood

Maternal diet does not influence milk Maternal diet does not influence milk calcium concentrationscalcium concentrations

– Does not appear that drinking more milk, Does not appear that drinking more milk, calcium supplements alter MEC excretion of calcium supplements alter MEC excretion of calcium into milkcalcium into milk

Different than Vit D, where maternal diet Different than Vit D, where maternal diet makes a differencemakes a difference

Calcium: IOM AI for Daily Calcium Intake Calcium: IOM AI for Daily Calcium Intake by Lactating Mothersby Lactating Mothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

1300 mg1300 mg 1000 mg1000 mg 1300 mg1300 mg 1000 mg1000 mg

Source: IOM DRIs, 2001

MicronutrientsMicronutrients

Independent of Mom: Fe, Zn, CuIndependent of Mom: Fe, Zn, Cu

Dependent on Mom: Se, I, Fl, MnDependent on Mom: Se, I, Fl, Mn

Vectoral Micronutrient Transport by MECVectoral Micronutrient Transport by MEC

4 Fe2+

MilkMilk

Nutrient(maternal)

Nutrient(fetal)

Importer Receptor(TfR, Zip3,Ctr1)

Nutrient

Transporter

IntracellularUnloading

Exporter(FPN, Znt, ATP7)

NutrientProtein binding

Endosome

Maternal Blood

Binding Protein

Micronutrients: IronMicronutrients: Iron

Breast milk quite low in iron concentration Breast milk quite low in iron concentration compared to formula (0.3 to 0.5 mg/L vs 4.5 to 12 compared to formula (0.3 to 0.5 mg/L vs 4.5 to 12 mg/L)mg/L)

– More bioavailable (50% vs 4-33%)More bioavailable (50% vs 4-33%)

Iron transported actively across MEC using typical Iron transported actively across MEC using typical transporterstransporters

– Transferrin Receptor (uptake from serum)Transferrin Receptor (uptake from serum)

– Divalent Metal Transporter-1 (off loading intracellularly)Divalent Metal Transporter-1 (off loading intracellularly)

– Ferroportin (export to milk)Ferroportin (export to milk)

Picture of Iron transport in MECPicture of Iron transport in MEC

Kelleher and Lonnerdal, 2005

Iron: Does Maternal Diet Matter?Iron: Does Maternal Diet Matter?

Iron deficient mothers produce iron sufficient milkIron deficient mothers produce iron sufficient milk– Unclear if iron deficiency increases transporter expression to Unclear if iron deficiency increases transporter expression to

maintain milk iron content (as seen with intestine and placenta)maintain milk iron content (as seen with intestine and placenta)

However, no evidence in humans that increased iron However, no evidence in humans that increased iron intake influences milk iron contentintake influences milk iron content

– Likely due to highly regulated iron transport processLikely due to highly regulated iron transport process» Iron sufficiency decreases activity of iron transporters Iron sufficiency decreases activity of iron transporters

» Protects from iron overload in other systemsProtects from iron overload in other systems

– In rats, increased maternal dietary iron does increase maternal milk In rats, increased maternal dietary iron does increase maternal milk ironiron

More research neededMore research needed

IOM RDA for Iron Intake by Lactating IOM RDA for Iron Intake by Lactating MothersMothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

15 mg15 mg 18 mg18 mg 10 mg*10 mg* 9 mg*9 mg*

Source: IOM DRIs, 2001

* Assumes that lactation inhibits menstrual cycle

Micronutrients: ZincMicronutrients: Zinc

Milk zinc concentrations decrease over duration of Milk zinc concentrations decrease over duration of lactationlactation

– Drop rapidly after 6 monthsDrop rapidly after 6 months Zinc is actively transported across MECZinc is actively transported across MEC

– Zip family of transporter for uptake from maternal serumZip family of transporter for uptake from maternal serum

– ZnT families of transporters for secretion into milkZnT families of transporters for secretion into milk

Zinc content of milk not influenced by maternal Zinc content of milk not influenced by maternal dietdiet

Picture of Zinc transport in MECPicture of Zinc transport in MEC

Kelleher and Lonnerdal, 2005

IOM RDA for Zinc Intake by Lactating IOM RDA for Zinc Intake by Lactating MothersMothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

8 mg8 mg 8 mg8 mg 13 mg13 mg 12 mg12 mg

Source: IOM DRIs, 2001

Micronutrients: CopperMicronutrients: Copper

Milk copper concentrations decrease over duration Milk copper concentrations decrease over duration of lactationof lactation

– Drop rapidly after 6 monthsDrop rapidly after 6 months Copper is actively transported across MECCopper is actively transported across MEC

– CTR1 transporter for uptake from maternal serumCTR1 transporter for uptake from maternal serum

– ATP7a transporter for secretion into milkATP7a transporter for secretion into milk

Copper content of milk not influenced by maternal Copper content of milk not influenced by maternal dietdiet

Picture of Copper transport in MECPicture of Copper transport in MEC

Kelleher and Lonnerdal, 2005

IOM RDA for Copper Intake by Lactating IOM RDA for Copper Intake by Lactating MothersMothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

1300 mcg1300 mcg 1300 mcg1300 mcg 900 mcg900 mcg 900 mcg900 mcg

Source: IOM DRIs, 2001

Micronutrients That are Dependent on Micronutrients That are Dependent on Maternal Serum ConcentrationMaternal Serum Concentration

Se, I, Fl, Mn are related to maternal intakeSe, I, Fl, Mn are related to maternal intake SeleniumSelenium

– Necessary for normal iodine/thyroid statusNecessary for normal iodine/thyroid status

IodineIodine– Necessary for normal thyroid statusNecessary for normal thyroid status

FluorideFluoride– Necessary for bone/teethNecessary for bone/teeth

– No studies of metabolism of fluoride during lactationNo studies of metabolism of fluoride during lactation

ManganeseManganese– Necessary in enzymatic reactions (metabolism)Necessary in enzymatic reactions (metabolism)

IOM Recommendations for Selenium, Iodine, IOM Recommendations for Selenium, Iodine, Fluoride and Manganese during Lactation Fluoride and Manganese during Lactation

NutrientNutrient Non-Non-lactating lactating

14-18 y14-18 y

Non-Non-lactatinglactating

18-50y18-50y

LactatingLactating

14-18y14-18y

LactatingLactating

18-50y18-50y

Selenium Selenium 55 mcg55 mcg 55 mcg55 mcg 70 mcg70 mcg 70 mcg70 mcg

IodineIodine 150 mcg150 mcg 150 mcg150 mcg 290 mcg290 mcg 290 mcg290 mcg

FluorideFluoride 3 mg3 mg 3mg3mg 3mg3mg 3mg3mg

ManganeseManganese 1.6 mg1.6 mg 1.8 mg1.8 mg 2.6 mg2.6 mg 2.6 mg2.6 mg

Source: IOM DRIs, 2001

Selected VitaminsSelected Vitamins

FolateFolate

B6B6

B12B12

Vitamin AVitamin A

Vitamin DVitamin D

Three Patterns of Maternal Status-Milk Status Relationship

Courtesy of Kay Dewey

FolateFolate

Necessary for Necessary for – 1-carbon metabolism, cell division1-carbon metabolism, cell division– NeurodevelopmentNeurodevelopment

» Neural tube closure (peri-conceptional)Neural tube closure (peri-conceptional)» Cognitive development (late fetal, neonatal)Cognitive development (late fetal, neonatal)

Actively transported from mother to fetusActively transported from mother to fetus Maternal diet does not affect milk unless Maternal diet does not affect milk unless

mom very deficientmom very deficient

IOM RDA for Folate Intake by Lactating IOM RDA for Folate Intake by Lactating MothersMothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

400 mcg400 mcg 400 mcg400 mcg 500 mcg500 mcg 500 mcg500 mcg

Source: IOM DRIs, 2001

Vitamin B6Vitamin B6

Low B6 levels associated withLow B6 levels associated with– Abnormal maternal and infant behaviorsAbnormal maternal and infant behaviors

– Slower growth, especially after 4-6 monthsSlower growth, especially after 4-6 months

Maternal diet influences B-6 levelsMaternal diet influences B-6 levels– IndiaIndia

– USAUSA

IOM RDA for B6 Intake by Lactating IOM RDA for B6 Intake by Lactating MothersMothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

2 mg2 mg 2 mg 2 mg 1.2 mg 1.2 mg 1.3 mg1.3 mg

Source: IOM DRIs, 2001

Vitamin B12Vitamin B12

Low meat intake causes low B12 in milkLow meat intake causes low B12 in milk High prevalence in developing countriesHigh prevalence in developing countries

– 32% in Guatemalan lactating women32% in Guatemalan lactating women

Increased risk in subpopulations of developed countriesIncreased risk in subpopulations of developed countries– Maternal avoidance of animal source foods x 4 years causes low milk B12Maternal avoidance of animal source foods x 4 years causes low milk B12

– Vegan mothersVegan mothers

Effect on behavior and motor development in offspringEffect on behavior and motor development in offspring– Mechanism unknownMechanism unknown

IOM RDA for B12 Intake by Lactating IOM RDA for B12 Intake by Lactating MothersMothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

2.4 mcg2.4 mcg 2 mcg2 mcg 2.8 mcg2.8 mcg 2.8 mcg2.8 mcg

Source: IOM DRIs, 2001

Vitamin D, Breastfeeding and RicketsVitamin D, Breastfeeding and Rickets

Rickets thought to be disease of the pastRickets thought to be disease of the past– ““Disappeared” in early 1960s due to:Disappeared” in early 1960s due to:

» Recognition of role of sunlight in vitamin D Recognition of role of sunlight in vitamin D homeostasis; fortification of milkhomeostasis; fortification of milk

» Use of multivitamin prepsUse of multivitamin preps» Higher prevalence of formula useHigher prevalence of formula use» AAP CON recommended 200 IU/d starting at 2 AAP CON recommended 200 IU/d starting at 2

weeks of ageweeks of age

Prevalence: Is This A Real Problem?Prevalence: Is This A Real Problem?

Case reports of nutritional rickets pop up in late 1970sCase reports of nutritional rickets pop up in late 1970sIncreased case reports in last 20 yearsIncreased case reports in last 20 yearsExact prevalence remains unknown but prevalence of risk Exact prevalence remains unknown but prevalence of risk

factors increasingfactors increasing

– Less sun exposureLess sun exposure

– Higher prevalence of nursing Higher prevalence of nursing

– Decreased prescription of vitamins for nursing infantsDecreased prescription of vitamins for nursing infants

Milk Content of Vitamin D Milk Content of Vitamin D

Human milk (22 to 100 IU/L)Human milk (22 to 100 IU/L)– Varies with maternal diet, pigmentation/sun exposureVaries with maternal diet, pigmentation/sun exposure– Light pigmentationLight pigmentation 68 IU/L 68 IU/L– Dark pigmentation Dark pigmentation 35 IU/L 35 IU/L– Both fall far short of RDA/DRI (infant does not consume Both fall far short of RDA/DRI (infant does not consume

1L until 14 lbs=5-6 months of age)1L until 14 lbs=5-6 months of age)– Maternal 3000 IU/d supplement-> 100 IU/LMaternal 3000 IU/d supplement-> 100 IU/L– New data from Bruce Hollis’ group-> Maternal New data from Bruce Hollis’ group-> Maternal

supplementation with 10,000 IU/d is safe and keeps infants supplementation with 10,000 IU/d is safe and keeps infants vitamin D sufficientvitamin D sufficient

» Not in practice yet pending larger studyNot in practice yet pending larger study

IOM AI for Vitamin D Intake by Lactating IOM AI for Vitamin D Intake by Lactating MothersMothers

Non-lactating Non-lactating 14-18 years14-18 years

Non-lactating Non-lactating 18-50 years18-50 years

Lactating Lactating

14-18 years14-18 years

LactatingLactating

18-50 years18-50 years

200 IU200 IU 200 IU200 IU 200 IU*200 IU* 200 IU*200 IU*

Source: IOM DRIs, 2001

Summary of Micronutrient Groups in LactationSummary of Micronutrient Groups in LactationGroup IGroup I

Milk concentration correlated with maternal Milk concentration correlated with maternal status, infant rapidly depleted. Supplements status, infant rapidly depleted. Supplements level in milk. level in milk.

Group IIGroup II

Milk concentration relatively independent Milk concentration relatively independent of maternal status, mother may become of maternal status, mother may become depleted. Supplements have little or no depleted. Supplements have little or no effect on milk level.effect on milk level.

Examples: ThiaminExamples: Thiamin

RiboflavinRiboflavin

Vitamin B-6Vitamin B-6

Vitamin B-12Vitamin B-12

Vitamin AVitamin A

IodineIodine

SeleniumSelenium

Examples: FolateExamples: Folate

CalciumCalcium

IronIron

CopperCopper

ZincZinc

Table courtesy of Dr. Kay Dewey

Summary: Clinical ImplicationsSummary: Clinical Implications

Some nutrients in human milk are not influenced by Some nutrients in human milk are not influenced by maternal diet unless the mother is very deficient; maternal diet unless the mother is very deficient; supplementation of sufficient mother doesn’t change milk supplementation of sufficient mother doesn’t change milk

Some nutrients are highly dependent on maternal dietSome nutrients are highly dependent on maternal diet Milk volume can potentially be increased by increasing Milk volume can potentially be increased by increasing

carbohydrate content of milkcarbohydrate content of milk– No clinical strategy to do this yetNo clinical strategy to do this yet

Summary: Clinical ImplicationsSummary: Clinical Implications

Milk fat content and composition highly influenced by Milk fat content and composition highly influenced by maternal dietmaternal diet

– Butter vs margarine? Ice cream?Butter vs margarine? Ice cream?

– Fish oil vs vegetable oil to increase DHAFish oil vs vegetable oil to increase DHA

Iron, zinc and copper all become very low after 6 Iron, zinc and copper all become very low after 6 months of lactationmonths of lactation

– Argument to start complimentary foodArgument to start complimentary food

Low meat consumption places B12 at riskLow meat consumption places B12 at risk Maternal supplementation with high dose Vitamin D Maternal supplementation with high dose Vitamin D

may get around supplementing infant (AAP rec.)may get around supplementing infant (AAP rec.)