the composition of breast milk: does maternal diet matter?
DESCRIPTION
The Composition of Breast Milk: Does Maternal Diet Matter?. Michael K. Georgieff, M.D. Professor of Pediatrics and Child Development Director, Center for Neurobehavioral Development University of Minnesota. Overview. Role of Breast Milk in Infant Nutrition Classes of Nutrients - PowerPoint PPT PresentationTRANSCRIPT
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.)