breastfeeding 2006. public health & breastfeeding maternal diet for lactation
TRANSCRIPT
Breastfeeding 2006
• Public health & breastfeeding
• Maternal diet for lactation
Healthy People 2010
HP Goals US Rates(1998)
WA rates
Earlypostpartum
75% 64% 88% (97-99)
At 6months
50% 25% NA
At one year 25% 16% NA
The resurgence of breastfeeding at the end of the second millennium. (Wright and Schanler, J Nutr. 131, 2001)• Between 1971 and 1995 increase was for
all groups.• Between 1984 and 1995 increase was in
groups less likely to breastfeed (low income, low education, African American, WIC)
• Early resurgence of breastfeeding concurrent to “natural childbirth” and women’s movement in white well educated families
More recent increases associated with:
• Increased knowledge of the benefits of breastfeeding by professionals (AAP 1997)
• Successful breastfeeding interventions - especially in WIC– 47% of US infants on WIC– early 90s brought increased WIC & for
breastfeeding promotion and increased maternal food package for BF
Source: 2003 National Immunization Survey, Centers for Disease Control and Prevention,Department of Health and Human Services
Percentage of Children Ever Breastfed by State
Percentage of Children Breastfed at 6 Months of Age by State
Source: 2003 National Immunization Survey, Centers for Disease Control and Prevention,Department of Health and Human Services
Percentage of Children Breastfed at 12 Months of Age by State
Source: 2003 National Immunization Survey, Centers for Disease Control and Prevention,Department of Health and Human Services
Who Breastfeeds? (Data source: Mothers’ Survey, Abbott Laboratories, Inc., Ross Products
Division)
Early 6 months 1 year
Less than highschool
48 23 17
High schoolgraduate
55 21 12
At least somecollege
55 21 12
Collegegraduate
78 40 22
Who Breastfeeds?, cont.
Early 6 months 1 Year
AfricanAmerican
45 19 9
Hispanic/Latino
66 28 19
White 68 31 17
Who Breastfeeds? NIS, 2002
• Statistically significant differences between groups for exclusive breastfeeding at 6 months:
• White child (15%) compared to Black (5%)• Eligible for WIC but not receiving (22%)
compared to on WIC (10%)• In day care at 6 months (11%) compared to
not in day care (15%).College educated mom (19%) compare to other education levels (11-12%)
• Married (15%) compared to unmarried (9%)• < 100 % poverty (11%) compared to >350 %
poverty (17%)
Ruowei et al. Pediatrics, 2005
Why do we care?
Breastfeeding and the Use of Human Milk
American Academy of Pediatrics, 2005
• “Human milk is species-specific, and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding.”
Health Benefits for Infant• Lowered risk of infectious diseases in both
developed and developing countries: diarrhea, respiratory tract infection, otitis media, bacterial meningitis, botulism, UTI, necrotizing enterocolitis, bacteremia
• Enhanced immune response to polio, tetanus, diptheria, haemophilus influenza immunization
• Possible lowered risk of sudden infant death syndrome
• Possible lowered risk of diabetes (type 1 & 2),leukemia, Hodgkin disease, lymphoma
• Probable enhanced cognitive development• Provides analgesia to infants during painful
procedures
Health Benefits for Mother
• Possible reduction in hip fractures after menopause
• Less postpartum bleeding & more rapid uterine involution
• Reduced risk of breast and uterine cancer
• Increased child spacing
Community Benefits
• Decreased annual health care costs of 3.6 billion in US
• Decreased cost of WIC• Decrease in costs associated with
infant illness - parental time lost from work
• Less environmental burden (no cans, no transportation & manufacturing)
The Economic Benefits of Breastfeeding: A
Review and Analysis. Jon Weimer. Food and Rural Economics Division, Economic Research Service,U.S. Department of Agriculture. Food
Assistance and Nutrition ResearchReport No. 13., 2001
Breastfeeding and Long Term Risk of Obesity for the Infant
Risk of Later Obesity Associated with Rapid Weight Gain in
InfancyAge at Follow
up (years)Odds Ratio
Stettler, 2002
7 1.38(1.32-1.44)
Stettler, 2003
20 5.22(1.55-17.6)
Toschke, 2004
5-7 5.7(4.5-7.1)
Breastfeeding studies: Challenges
• No consistent definition of “breastfeeding”• Mixture of prospective and cross sectional
approaches• Mixture of definitions of “obesity” and
ages of follow-up• Adjusted for wide variety of control
variables• Effects often seen in only one gender or
ethnicity
Breastfeeding as an Infant and Risk of Later Obesity
Classification of Breastfeeding
Odds Ratio
Armstrong, 2002
Exclusive at 6-8 weeks
0.70(0.61-0.80)
Bergmann, 2003
More than 3 months
0.46(0.23-0.92)
Gillman, 2001 Exclusive or mostly
0.78(0.66-0.91)
Hediger, 2001 Ever Exclusive 0.63(0.41-0.96)
Liese, 2001 Any breastfeeding
0.66(0.52-0.87)
Breastfeeding Studies, cont.Classification of Breastfeeding
Odds Ratio
Parsons, 2003 More than one month
Female 0.84 (0.67-1.05)
Male 0.93(0.74-1.17)
Toschke, 2002 Any breastfeeding
0.80(0.66-0.96)
Von Kries, 2000
Ever exclusive 0.75 (0.57-0.98)
Von Kries, 2002
Any breastfeeding
0.91(0.60-1.38)
Large Breastfeeding Studies without Odds Ratios
• Eriksson, 2003: cumulative lifetime incidence of BMI > 30Kg/m2 not associated with breastfeeding
• Li, 2003: Risk of BMI >95% not significant at ages 4-8 or 9-18.
• Poulton, 2001: Risk of overweight not significant at 3,5,7,9,11,13,15,18,21 or 26 years.
Grummer-Stawn, 2004
• Study included 12,587 US girls and boys served by WIC and Child Health Block Grant
• Follow-up was at 4 years• Classification of exposure was by months• Breastfeeding had protective effect in white
non-Hispanic low income children, but not when all racial/ethnic groups were combined.
Recent Reviews & Meta-analysis• Owen et al. Pediatrics. 2005
– 61 studies– Odds ratio = 0.87 (95% CI 0.85-0.89) for
reduced risk of later obesity associated with breastfeeding compared to formula
• Arenz et al. Int J obes relat metab disord. 2004– 9 studies met criteria– Odds Ratio = 0.78, 95% CI (0.71, 0.85)
protective effect of breastfeeding for obesity– Found dose response
• Harder et al. Am J Epidemiol. 2005
Harder et al. Am J Epidemiol. 2005 (17 studies)
Length of Breastfeedi
ng
Odds Ratio for Risk of Obesity
95% CI
< 1 1.00 0.65, 1.55
1-3 0.81 0.74, 0.88
4-6 0.76 0.67, 0.86
7-9 0.67 0.55, 0.82
9 0.68 0.50, 0.91
Breastfeeding & Obesity: Support for the Evidence
• Secular trends– Trend for increased breastfeeding is opposite
that for obesity• Dose Response
– Some studies find, others do not• Plausible mechanisms
– Bioactive components of human milk– Changing composition of human milk during
feedings– Lower energy and protein intake in breastfed
infants– Insulin response to feeding– Differences in the feeding relationship
Breastfeeding: What can we say?
• Early studies flawed and inconclusive (Butte, Ped Clin N Amer, 2001)
• Some studies, especially cross sectional studies based on parental report years after infancy, found some protective effects (Toschke, J Pediatr 2002, Gillman, JAMA 2001, Hediger, JAMA 2001)
• Prospective studies have mixed results.
• Any protective effects of breastfeeding may not be detectable in the face of other more powerful risk factors
Dubois et al. Public Health Nutrition, 2003
• Social inequalities in infant feeding during the first year of life. The Longitudinal Study of Child Development in Quebec (LSCDQ 1998-2002)
• “Social disparities in diet during infancy could play a role in the development of social and health inequalities more broadly observed at the population level.”
HHS Blueprint for Action for Breastfeeding - 2000
• Health Care System• Worksites• Family and Community • Research
・ A written breastfeeding policy that is communicated to all healthcare staff
・ Staff training in the skills needed to implement the policy ・ Education of pregnant women about the benefits and management of breastfeeding ・ Early initiation of breastfeeding ・ Education of mothers on how to breastfeed and maintain lactation ・ Limited use of any food or drink other than human breast milk ・ Rooming-in ・ Breastfeeding on demand ・ Limited use of pacifiers and artificial nipples ・ Fostering of breastfeeding support groups and services
Practices for Successful Breastfeeding Services at Hospital and Maternity
Centers
Child Care
• It is also important that childcare facilities be supportive of breastfeeding. Childcare centers should make accommodations for mothers who wish to breastfeed their children or have their children fed expressed milk.
Worksites
Pubic Education and Support
• Access to lactation consultants and/or peer support
• School health education should include the benefits of breastfeeding for mother and child
• Campaigns should be directed at fathers• Social marketing campaign: breastfeeding
is the “normal” way to feed infants in most places that mothers and infants go.
Needed Breastfeeding Research
• Social, cultural, economic and psychological factors that influence infant feeding decisions
• Improve understanding of health benefits – especially among disadvantaged children
• Monitor trends of incidence, duration, exclusivity, partial and minimal breastfeeding among minority and ethnic groups
• Compare cost effectiveness of breastfeeding promotion programs
Research needs, cont.
• Role of fathers• Impact of brief postpartum hospital
stays• Safety of over the counter meds• Effects of breast implants on
childhood disorders
Pisacane et al. A controlled trial of the father’s role in breastfeeding
promotion. Pediatrics, 2005.
• 560 mother/father dyads– All mothers received breastfeeding support and
advice– 280 fathers were randomized to a 40 minute training
session about management of breastfeeding
• At 6 months:– 25% of intervention group was fully breastfeeding
compared to 15% of control group– Significant differences also in: any breastfeeding at
12 months, perceived milk insufficiency– 24% of women who experienced problems in
intervention group were still breastfeeding at 6 months compared to just 4.5% of women with problems in control group.
Maternal Diet and Breastfeeding
Basics
• There is no one optimal set of rules for maternal diets
• Women may choose not to breastfeed if the recommended dietary limitations and requirements are perceived as too difficult to follow
Basics
“A balanced diet without excessive supplementation is the most physiologic and economic way to ensure good milk.”
Ruth Lawrence, 1998
Basics
IOM: Women are able to….“produce
milk of sufficient quantity and quality to support growth and promote the health of infant - even when the mother’s supply of nutrients is limited.”
Maternal Diet and Milk Production
• In extreme famine and malnutrition milk supply does eventually stop
• In more moderate deprivation, like the Dutch famine, milk production decreased slightly, but was maintained at the expense of maternal tissue.
• Effects of deficiencies may start at 1500 kcal/day
Energy
• Wide variation between women & their infants
• Dependent on maternal stores• 1989 RDA: 500 kcal/day over
reference • Energy sparing adaptations
– decreased BMR – decreased postprandial thermogenesis– decreased physical activity
2002 DRI for Energy
• Lactation energy needs calculated as: EER + milk energy requirement - weight
loss
• Baseline for women older than 18 = 2,403
• First six months of lactation for women older than 18 is 2,773
• Second six months of lactation for women older than 18 is 2,803
2002 DRI for Energy• BMR, BEE, TEF - current
information is non-conclusive regarding effects of lactation.
• Physical activity: tends to be lower during early lactation but highly variable beyond early period.
• Milk energy output increases during first 6 months& is highly variable for second six months depending on weaning.
2002 DRI for Energy
• Mean milk production: 0.76 for first six months, 0.6 in second six months. Mean energy density of human milk is 0.67 kcal/g
• Mean kcals from milk output = 483-538 kcal/day
• In general, well nourished women loose .8 kg per month in first 6 months.
EER for Lactation
• 1st 6 months: EER + 500 - 170 (milk energy output minus weight loss)
• 2nd six months: EER + 400 - 0
Mean Maternal Energy Costs of Lactation
Age in Months Volume of milkper day (oz)
Total EnergyCost (kcal)
1 20 4462 28 6263 31 6924 32 7145 34 7426 37 819
Symposium: Maternal body composition, caloric restriction and exercise during lactation (Dewey, J Nutr, 1998)
• For women with adequate stores, moderate weight loss does not adversely affect milk energy output.
• Thin women will maintain milk energy output in the normal range as long as they are in neutral or positive energy balance.
• It is only when thin women are in negative balance that milk energy output will be affected.
Maternal energy balance (kcal/day)
0negative
positive
Milk
energy
output
Kcal/day
500Maternal Energy Reserves > x
Maternal energy
reserves < x
Symposium: Maternal body composition, caloric restriction and exercise during
lactation (Dewey, J Nutr, 1998)
• Protective factors when mothers are in negative energy balance:– a high level of aerobic exercise enhances
body fat mobilization during lactation.– prolactin levels rise with exercise and
negative energy balance leading to mobilization of fatty acids from adipose tissue or diet for milk synthesis (increased mammary lipoprotein lipase)
– Frequency and intensity of infant sucking affect endocrine and autocrine regulation of milk synthesis.
Randomized trial of the short-term effects of dieting compared with dieting plus aerobic exercise on lactation performance (McCrory, AJCN, 1999)• 3 groups of breastfeeding women ~12
weeks pp, on study for 11 days:– 35% energy deficit from diet alone (n=22)– 35% energy deficit from diet and exercise
(n=22)– control group (n=23)
• No significant difference in:– milk volume, composition, or energy output– infant weight
Randomized trial of the short-term effects of dieting compared with dieting plus
aerobic exercise on lactation performance (McCrory, AJCN, 1999)
Control Diet Diet & Exercise
Baseline wt. 68.5 68.3 69.0
Weight change -0.2(-0.5,0.1)
-1.9(-2.2,-1.6)
-1.6(-1.9,-1.4)
Baseline % bodyfat
32.0 32.5 32.9
% body fat change -0.5(-1.2,0.2)
-0.9(-1.3,-0.5)
-1.6(-2.3,-0.9)
Randomized trial of the short-term effects of dieting compared with dieting plus
aerobic exercise on lactation performance (McCrory, AJCN, 1999)
• Interaction between group and baseline % body fat– diet only group: milk energy output
increased in fatter women & decreased in leaner women
• Plasma prolactin concentration was higher in energy deficit groups than the control group.
Lactation & Risk of Maternal Obesity
• In the early postpartum period lactating women do not loose weight faster than women who do not lactate. (Gunderson, 2000)
• Exclusive lactation for several months may be associated with increased weight loss of 2 Kg in some women. (Dewey, 1993; Gunderson, 2000)
• In large populations of women, “weight reduction associated with lactation is minimal.” (Sichieri, 2003)
Impact of Breastfeeding on Maternal Nutritional Status
(Dewey, 2004)• Higher quality studies find that
degree of breastfeeding affects maternal weight loss at 3-6 months.
• Effect is small and may not be detectable in studies that do not measure exclusivity and/or duration.
The Impact of Maternal Lactation is Difficult to Study
• Relationship between lactation and weight loss is confounded by smoking, return to work, and “dieting.”
• Protective biological mechanisms may preserve maternal fat during lactation in order to assure adequate energy stores.
• Maternal weight loss during lactation is highly variable and is associated with gestational weight gain, cultural practices, physical activity and food availability (Butte, 1998)
Protein
• Protein content per volume is sufficient even in malnourished women
• Supplementation of malnourished women increases total milk volume, but doesn’t increase % of kcal from protein
Cholesterol
• Fat globule membrane includes cholesterol and phospholipids
• Human milk has high levels of cholesterol; formula has none.
• Proportions of cholesterol in human milk are not influenced by maternal diet.
Fatty Acids
• Maternal diet has no effect on total % fat content of milk, but does influence kinds of fatty acids.
• When mother is in energy balance, about 30% of fatty acids in milk comes from mother’s diet.
• Mammary gland can synthesize n-9 fatty acids up to 16-C.
Is FA composition of milk associated with risk of
obesity?• Aihaur and Guesnet. Obesity
Reviews. 2004• N-6 PUFAs are potent promoters of
adipogenesis and adipose tissue development
• Percent of US infants > 95%:– 1970s: 4.0% (boys); 6.2% (girls)– Early 90s: 7.5% (boys); 10.8% (girls)
Aihaur and Guesnet
Essential fatty acid requirements of vegetarians in pregnancy, lactation, and infancy (Sanders, AJCN, 1999)
• Many vegans and vegetarians have diets high in n-6 fatty acids and low in n-3– ratios of 15:1 to 20:1 of linoleic to -
linolenic have been reported
Essential fatty acid requirements of vegetarians in pregnancy, lactation, and
infancy (Sanders, AJCN, 1999)
18:2n-6Linoleic
18:3n-3-linolenic
18:4n-6
g/day
18:5n-6 18:6n-3 linolenic
Vegans 21.4 1.2 0 0 0
Vegetarians 14.6 1.5 trace trace trace
Omnivores 9.1 1.1 0.15 0.09 0.04
Essential fatty acid requirements of vegetarians in pregnancy, lactation, and
infancy (Sanders, AJCN, 1999)
• Lower DHA levels have been observed in blood and artery phospholipids of infants of vegetarians.
• Recommendations: – avoid excessive intakes of linoleic acid– recommended ratio of n-6 to n-3 is 4:1
to 10:1
Carbohydrate
• Lactose concentration is very stable and is not affected by maternal diet
Water
• “Forced” drinking is counter-productive
• Illingworth and Kirkpatric (1953) reported that mothers produced less milk and babies gained less weight when they were forced to consume 107 oz per day compared to mothers with ad lib intakes averaging 69 oz per day.
Water
“When fluids are restricted, mothers will experience a decrease in urine output, not in milk.”
Lawrence, 1998
Vitamins & Minerals
• Allen. Am J Clin Nutr. 2005. Multiple micronutrients in pregnancy and lactation: an overview.– Maternal micronutrient status should be
viewed as a continuum through periconceptual period, pregnancy & lactation.
– Multiple micronutrient deficiencies occur simultaneously when diets are poor
Allen, cont.
• Priority nutrients for lactation based on relation between maternal status and breastmilk composition:– Thiamin, riboflavin, B6, B12, vitamin A, iodine
• For these nutrients poor maternal status in pregnancy can lead to poor infant stores that are exacerbated by low breastmilk content in developing countries
IOM Nutrient Recommendations
• Examined US nutrient densities at 3 levels of energy intake:– 2700 (RDA for lactation)– 2200 (actual reported intakes)– 1800 (minimal level that should be
considered on a restricted diet during lactation)
2700 2200 1800Calcium X X XZinc X X XMagnesium X XThiamin X XB6 X XRiboflavin XFolate XPhosphorus XIron X
Low Nutrient Intakes at Given Energy Levels in US
IOM Recommendations
• Lactating women should be encouraged to obtain their nutrients from a well-balanced varied diet rather than from vitamin-mineral supplements. Specifically:
• Eat a wide variety of breads and cereal grains, fruits, vegetables, milk products, and meats or meat alternates each day.
• Take three or more servings of milk products daily.
• Make a greater effort to eat vitamin A-rich vegetables or fruits often.
• Be sure to drink when you are thirsty. You will need more fluid than usual.
• If you drink coffee or other caffeinated beverages such as cola, do so in moderation. Two servings daily are unlikely to harm the infant. Caffeine passes into milk.
IOM Recommendations
• There should be a well defined plan for the health care of the lactating woman that includes screening for nutritional problems and providing dietary guidance.
• Women who plan to breastfeed or who are breastfeeding should be given realistic, health promoting advice about weight changes during lactation.
IOM Recommendations
• Health care providers should be informed about the differences in growth between healthy breastfed and formula fed infants.
• Steps should be taken to ensure adequate nutrition of all infants.