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.