Nutrition & Dietetics 2013; 70: 255–259
DOI: 10.1111/1747-0080.12067
CONTINUING EDUCATION
NUTRITION FOR THE BREASTFEEDING WOMAN
Continuing education and the APD program
Every contact between a lactating woman and a health professional who is
unfamiliar with current breastfeeding knowledge creates a potential barrier to
breastfeeding success and increases the risk of inappropriate use of artificial baby
milk.
APD Accredited
Practising
Dietitian
™
This Quiz has been developed by Jennifer Shirtcliff, Susie de Jersey, Joy Anderson and Breastfeeding Working Group Members on behalf
of the Pediatric and Maternal Health Interest Group. Further information can be obtained by contacting Jennifer Shirtcliff (jen.shirtcliff@
bigpond.com).
Introduction
Breastfeeding is the recommended sole source of nutrition
for infants up until 6 months of age, with continued breastfeeding with complementary feeding up until at least 12
months of age.1 Breastfeeding confers a range of health benefits for both mothers and infants. A woman’s nutritional
needs are greater during lactation than at any other time in
her life.2 There is sound evidence that a woman is able to
successfully breastfeed her child while under significant
physiological stress associated with malnutrition.3 However,
the influence of lactation on the nutritional status of a wellnourished woman is less understood and little work has
been done around the impact on the mother’s nutritional
status in a well nourished setting. While there are many
unanswered questions about nutrition and lactation, some
aspects are well understood. It is essential dietitians are
adequately equipped to support a breastfeeding mother with
appropriate knowledge of her nutritional needs.
1. Consumption of which of the following foods/fluids
will increase a mother’s milk supply?
a. Food galactogogues (e.g. fenugreek, oatmeal, fennel,
brewers yeast, and flax seed)
b. Water
c. Stout
d. None of the above
e. All of the above
2.
a.
b.
c.
d.
The energy cost of lactation is estimated to be:
1050 kJ/day
2100 kJ/day
2620 kJ/day
4280 kJ/day
3. (i). A breastfeeding woman must ensure an adequate
intake of the following nutrients to ensure that her
milk provides adequate levels of each to her infant:
a. Iron, fat soluble vitamins, calcium
b. Iron, zinc, iodine, B12
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© 2013 Dietitians Association of Australia
c. Omega-3 fatty acids, fat soluble vitamins
d. Iodine, zinc, omega-3 fatty acids, B12, vitamin D
e. Vitamin D and calcium
3. (ii). The breast milk content of which of the following
nutrients is independent of a mother’s intake and/or
nutrition stores?
a. Iron, fat soluble vitamins, calcium
b. Iron, zinc, iodine, B12
c. Omega-3 fatty acids, fat soluble vitamins
d. Iodine, zinc, omega-3 fatty acids, B12, vitamin D
e. Vitamin D and calcium
4. To reduce the risk of food allergies in her child, a
breastfeeding mother should:
a. Avoid all sources cows’ milk protein, gluten and nuts
until foods containing those proteins have been safely
introduced to her child after 6 months of age.
b. Follow a strict elimination diet covering all the major
allergens.
c. Consume an unrestricted diet, apart from any foods to
which the mother is allergic or intolerant.
d. Avoid foods members of her extended family and her
partner (father of the child) or partner’s extended family
have an allergy or intolerance to.
5. Which of the following statements is most true:
The alcohol content of breast milk:
a. is the same as the blood alcohol level of the breastfeeding
woman.
b. will contain the same amount of alcohol as the mother
has ingested in the previous 2 hours.
c. will be higher than the blood alcohol level of the
mother.
d. reflects the blood alcohol level of the mother 2 hours
previously.
e. will always be lower than the blood alcohol level of the
mother.
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Continuing Education
6. In regard to caffeine intake, breastfeeding mothers are
encouraged to:
a. Consume caffeine containing products in moderation
(about the equivalent of two cups of coffee per day), as
desired.
b. Consume as much as they like as their consumption will
not affect their breast milk and caffeine has no effect on
babies.
c. Consume at least 200 mg caffeine per day.
d. Avoid all sources of caffeine.
energy reservoir to meet part of the energy cost of milk
production. However, to prevent excessive weight loss, it
is recommended that a woman’s energy intake increase
by approximately 2000 kJ/day during lactation.6,10
Women who have not laid down a sufficient fat store
during pregnancy may have greater energy requirements
during lactation while those who have gained excess
weight during pregnancy may need to consume less
additional energy while breastfeeding to allow for use of
existing body stores.9,10
Answers
3. (i). d
1. d
Milk supply is closely dependent on the removal of milk
from the breast by the infant (or other mechanism such as
expression). Frequent and thorough drainage of the
breasts typically results in an increased rate of milk secretion.4 Women experiencing difficulties with milk supply
or a low rate of milk production should be evaluated by
a lactation expert to assess efficacy of infant milk transfer
and appropriate feeding pattern. A lactation consultant or
breastfeeding medicine specialist may address comfort
and relaxation of the mother, underlying medical conditions, adequacy and thoroughness of milk removal by
ensuring optimal attachment, and assist with technique
used for milk expression.4
Galactogogues (medications or other substances believed
to assist initiation, maintenance or augmentation of the
rate of maternal milk synthesis) may be prescribed in
situations where non-pharmacological interventions have
not resulted in improved milk supply. The evidence
around the efficacy and safety of pharmaceutical galactogogues (such as domperidone (Motilium) and metoclopramide (Maxalon) ) is weak.4Traditional food and herb
galactogues (such as fenugreek, milk thistle (Silybyn marianum), beer (barley component of beer), marshmallow,
anise, basil, seaweed, millet, dandelion, oats, fennel
seeds) have little empirical evidence to support their efficacy and safety.4,5
Water—breastfeeding mothers are encouraged to drink
to satisfy their thirst and to use thirst as a primary indicator of adequate fluid intake. The RDI for fluid for
lactating women is higher than for non-lactating women
and is representative of the amount of milk provided to
the infant.6 Increasing fluid intake has not been shown to
increase milk volume, nor does fluid restriction decrease
it.7,8
3. (ii). a
Overall, human milk concentration of different vitamins
and minerals is not dependent on maternal diet: rather,
the composition of human milk usually remains unaffected even in situations where the mother’s diet is poor.2
The nutrient profile of a well-nourished woman’s milk
will not vary substantially with a change in diet for most
nutrients.10 However, there are some micronutrients
where adequacy in human milk is closely linked to maternal intake (such as vitamins A, B12, B6 and iodine).13 Little
research has been conducted into the impact that lactation has on maternal micronutrient status, particularly in
developed countries and compared to non-lactating
women. During lactation there is an increased requirement for vitamins A, B6 and C and iodine and zinc.14 It is
important to remember that maternal nutrient stores may
become depleted even though milk concentrations are
adequate. Table 1 provides more detail of maternal intake
and status of individual micronutrients and the effect on
breast milk composition.
2. c
Exclusively breastfeeding an infant for 6 months uses an
average of 2620 kJ/day.9,10 However, energy utilisation
varies significantly during lactation (depending on milk
volume produced and energy density of that milk).9
Studies in developing countries have shown that women
are able to lactate successfully while consuming much
less than the recommended energy intake.9,11,12 In wellnourished populations, a mother’s fat stores provide an
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4. c
There is insufficient evidence to recommend maternal
diet exclusions during pregnancy and lactation to reduce
the risk of allergy development in infants.31–34 The management of a child with a diagnosed food allergy is different to prevention of allergy and requires specialised
dietetic management.
5. a
From about half an hour after a breastfeeding mother has
consumed an alcoholic beverage, levels of alcohol in
human milk will be equal to the blood alcohol level of the
mother.35,36 Maternal alcohol consumption has been
found to have a negative impact on lactation performance, primarily through interference with the milk ejection reflex and changes in oxytocin and prolactin levels,
which in turn may impact on milk production.35,36 Presence of alcohol in human milk consumed by infants
results in low blood alcohol levels in the infant. Some
studies have observed effects on the infant’s alertness and
disturbances of sleep patterns.35,36
Studies looking at the consumption of alcohol by breastfeeding women have found that less than 50% consumed
alcohol during the period studied and the majority of
© 2013 Dietitians Association of Australia
Continuing Education
Table 1 Nutrient composition of breast milk relative to maternal intake or stores
Micronutrient composition of breast milk dependent on maternal intake/stores
Iodine
The iodine content of human milk is dependent on the iodine status of the mother.13 Infants
are completely dependent on the iodine in human milk for accumulation in the thyroid
and production of thyroid hormone.
Zinc
The requirement for zinc during lactation is increased. Vegetarians and vegans may require
higher intakes of foods containing zinc to ensure adequate absorption from less bioavailable
sources.6,15,16 Chronic low zinc intake in mothers appears to be associated with low milk
zinc levels, however, maternal supplementation has no significant effect on milk zinc levels
in the short term for mothers with adequate zinc levels.13,17
Fatty acids
When a woman is in energy balance, fatty acids from her diet account for approximately 85%
of the total fatty acids in her milk.18 It is possible to change the concentrations of different
fatty acid components by altering the maternal diet. A single dose of a specific dietary fat
results in an increase in the human milk content of that fat 6 hours after its ingestion and
remains significantly elevated for 1–3 days.18,19 A low-fat, high-carbohydrate diet increases
fatty acid synthesis in the breast.19 Fat content of human milk also changes when mothers
consume a high fat diet (such as an Atkins diet) for weight loss20 and with the
consumption of dairy fat.21
Vitamin B12
Vitamin B12 deficiency has been reported in breastfed infants whose mothers have low levels
of B12. Vegan mothers and those with pernicious anaemia are most at risk. As vitamin B12
is water-soluble, current maternal intake is an important factor in determining its
transplacental and mammary transfer.22
Water-soluble vitamins
The concentrations of water-soluble vitamins in human milk can be affected by the maternal
diet.
Fat-soluble vitamins
Fat-soluble vitamin concentrations are less affected by maternal diet, but it is important that
(A, E, and K)
the dietary intake is sufficient to maintain maternal body stores.
Vitamin D
Maternal and infant vitamin D levels are mainly derived from exposure to ultraviolet B light
in sunlight with some also obtained from food sources.23–25 If a mother is deficient in
vitamin D, her milk levels will also be low, placing her infant at high risk of deficiency
as well.26,27 Supplementation with vitamin D is recommended for infants of veiled or
dark-skinned mothers and others at risk of deficiency.24 There is some evidence that
supplementation of the mother is an acceptable mechanism for achieving vitamin D
adequacy in the infant,27 although supplementation with vitamin D has the potential to
be toxic if excess amounts are given.28
Micronutrient composition of breast milk independent of maternal intake/stores
Iron
Iron content of human milk is not affected by maternal iron status.13 Exclusive breastfeeding
for 6 months uses about half the iron normally lost through menstruation for that length
of time. The iron requirements for lactating women (particularly those exclusively
breastfeeding infants up to 6 months of age) are not as high as for non-lactating
women.3,6,14
Calcium
During the first 3–6 months, breastfeeding is associated with a reduction in maternal bone
mineral content that is greater than that observed in the postpartum period in non-lactating
women. Bone mineral content increases during later lactation and after weaning, even in
women who breastfeed into the second and third year after birth. Changes in bone mineral
content associated with lactation are reversible and by 3 months after weaning there is little
difference between women who have breastfed and those who have not.29
For women who conceive during lactation, this increase in bone mineral content appears to
occur during pregnancy. Individual variations in change in bone mineral content are large and
not related to a woman’s initial bone mineral status or her dietary calcium intake.29
Randomised controlled trials of calcium supplementation have not shown an effect on changes
in bone mineral content, human milk calcium concentration, fractional calcium absorption or
biochemical markers of bone turnover, even in women with very low calcium intakes.30
those who did consumed two standard drinks.35,37 The
National Health and Medical Research Council (NHMRC)
recommends that the safest option for breastfeeding
women is to avoid alcohol consumption. However, they
acknowledge that abstinence may not be the preference
© 2013 Dietitians Association of Australia
of some women and the risks to the infant associated with
artificial feeding far outweigh the risks associated with
exposure to small amounts of alcohol. The NHMRC recommends that women abstain from drinking alcohol
during the first month of their infant’s life until the milk
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Continuing Education
•
•
•
•
supply is well established and babies feeding patterns
become more predictable. When they do choose to drink,
mothers are encouraged to consume no more than two
standard drinks in one day. To further minimise alcohol
exposure of her infant it is recommended that the
mother:
Breastfeed her infant before consuming alcohol and wait
about 2 hours (per standard drink) after consuming
alcohol before breastfeeding.
Eat before and during alcohol consumption
Choose low-alcohol products and/or alternate alcoholic
drinks with non-alcoholic drinks.
Express and store human milk prior to consuming moderate to large amounts of alcohol.36
6. a
Caffeine appears in human milk rapidly after maternal
ingestion.38,39 However, the level in the milk is low at
about 1% of the level of the mother’s plasma concentration.39 The amount of caffeine in human milk peaks about
1 hour after consumption by the mother.38 Very high
caffeine intakes have been linked to fussiness, jitteriness
and poor sleep patterns in some infants.39 The unsettled
symptoms in the infant tend to disappear after removal of
caffeine from the mother’s diet for a couple of days.
Caffeine accumulates in infants, particularly newborns
and premature infants as it is metabolised very slowly.38,39
The clearance rate of caffeine in infants reaches that of
adults by about 3–5 months of age.38 It is generally recommended that a moderate intake of caffeine (about two
to four cups of tea or coffee per day) is acceptable during
breastfeeding.40
Further Reading
Further information can also be found in: Brodribb WE
(editor). Breastfeeding Management in Australia 4th Edition.
East Malvern: Australian Breastfeeding Association.
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