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Patient education: Maternal health and nutrition during breastfeeding (Beyond the Basics)

Authors
Nancy F Butte, PhD
Alison Stuebe, MD, MSc
Section Editors
Steven A Abrams, MD
Kathleen J Motil, MD, PhD
Deputy Editor
Alison G Hoppin, MD
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BREASTFEEDING AND HEALTH OVERVIEW

Exclusively breastfeeding mothers use about 500 calories a day to make milk for their babies. While undernourished mothers can produce milk, breastfeeding women do need an increased number of calories and nutrients to maintain their own nutrient stores, allowing for gradual loss of the weight that they gained during pregnancy.

In most cases, the best way to get adequate dietary energy (calories) and nutrients is to eat a healthy, well-balanced diet that includes fruits, vegetables, protein, grains, and a limited amount of fat, sometimes with a multivitamin supplement. The components of a healthy diet are discussed in depth in a separate topic review. (See "Patient education: Diet and health (Beyond the Basics)".)

This topic review discusses the nutritional needs of women who are breastfeeding, including recommendations for calorie intake, vitamin and mineral supplements, fluid recommendations, and guidelines for weight loss while breastfeeding. Foods, drinks, and medications that should be limited or avoided are also discussed.

Topic reviews about the basics of breastfeeding and common breastfeeding problems are also available. This topic discusses how to prepare to breastfeed, including the benefits of breastfeeding. Additional breastfeeding topics are available separately. (See "Patient education: Common breastfeeding problems (Beyond the Basics)" and "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)".)

NUTRITION AND BREASTFEEDING

Caloric recommendations — The energy, or calorie, needs of a woman when she is not breastfeeding varies depending on many individual factors, including her weight, age, height, and activity level. Typical needs are outlined in the table (table 1).

A woman who is breastfeeding has the following additional energy needs:

From birth through six months after birth – 330 calories per day more than women who are not breastfeeding, allowing for gradual loss of the weight gained during pregnancy. This assumes that the infant is fed only breastmilk, and no formula or solid foods.

From six to 12 months after birth – 400 calories per day more than women who are not breastfeeding. This assumes that the woman has lost the weight she gained during pregnancy and is keeping a stable body weight. This assumes that the infant is fed only breastmilk (no formula), and solid foods starting around six months of age.

This amounts to total energy needs ranging from 2100 calories to 2800 calories per day for the first six months of lactation, and 2200 to 2800 calories per day thereafter, depending on the mother’s age, weight, and activity level. The energy needs also depend on when and how fast the infant is weaned.  

Fluid intake — The average woman who breastfeeds exclusively produces approximately 25 ounces (750 mL) of breast milk per day. Many women wonder how much extra fluid they should drink given this relatively large loss of fluid. It is generally sufficient for a woman to drink when she is thirsty and to watch for early signs that she is not getting enough fluids (eg, dark-colored urine, infrequent urination, dry mouth). To encourage an adequate fluid intake, some clinicians recommend keeping a bottle of water or another healthy beverage nearby.

WEIGHT LOSS AND BREASTFEEDING

Following pregnancy, most women lose weight gained during pregnancy gradually. Losing a moderate amount of weight by eating less and/or exercising does not usually affect a woman's ability to produce an adequate amount of breast milk.

Women who have had weight loss surgery and have reached a stable lower body weight can breastfeed successfully. They should continue their vitamin and mineral supplements and should be monitored for nutrient deficiencies, such as vitamin B12 deficiency. (See "Patient education: Weight loss surgery and procedures (Beyond the Basics)".)

VITAMIN AND MINERAL REQUIREMENTS WHILE BREASTFEEDING

Women who are healthy and eat a well-balanced diet that includes meat and fish do not usually need to take a vitamin supplement while breastfeeding. However, all women, including those who breastfeed, should ensure that they consume an adequate amount of calcium and vitamin D. (See 'Calcium' below.)

Vegans — Women who are healthy but who do NOT eat meat, chicken, fish, or dairy products need to take a vitamin supplement that contains vitamin B12. Most commercially available multivitamins contain an adequate dose of B12.

Calcium — Pregnancy and breastfeeding cause a temporary decrease in bone mass. However, lost bone is usually regained after a woman stops breastfeeding. This loss cannot be prevented by consuming additional calcium during pregnancy or while breastfeeding. All adult women should consume a daily minimum of 1000 mg of calcium; adolescents should consume 1300 mg of calcium per day.

The primary sources of calcium in the diet are milk and other dairy products, such as hard cheese, cottage cheese, or yogurt, as well as green vegetables, such as spinach (table 2). If it is not possible to consume enough milk or other foods that contain calcium, it is reasonable to take a calcium supplement (table 3). (See "Patient education: Calcium and vitamin D for bone health (Beyond the Basics)".)

Vitamin D — Absorption of calcium depends upon having an adequate level of vitamin D. Both breastfeeding and nonbreastfeeding women require an estimated 600 int. units per day of vitamin D. Vitamin D fortified milk is a good source of dietary vitamin D, providing approximately 100 int. units per cup. A supplement providing vitamin D alone, or calcium plus vitamin D, is also a good source of vitamin D. (See "Patient education: Calcium and vitamin D for bone health (Beyond the Basics)".)

Of note, breastfed infants should be given their own vitamin D supplement, even if the mother is taking the recommended amount of vitamin D. This is because breastmilk is low in vitamin D. (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Vitamin D'.)

Iron — Women who are not anemic after delivery and who breastfeed exclusively do not usually need an iron supplement. This is because they usually do not have a menstrual period for the first four to six months, so there is little iron lost in menstrual blood. The recommended dietary allowance of iron for adult breastfeeding women is 9 mg daily, compared with 18 mg for women who are not breastfeeding. For breastfeeding women, prenatal vitamins contain greater-than-needed amounts of iron, which can cause constipation. Breastfeeding women who choose to take a multivitamin may prefer a regular multivitamin that has lower amounts of iron, rather than a prenatal vitamin.

Women who are anemic after delivery usually require an iron supplement; this may be provided via an over-the-counter or prescription iron supplement, or by using a prenatal multivitamin supplement. The recommended type and dose of iron should be discussed with a healthcare provider. (See "Patient education: Anemia caused by low iron in adults (Beyond the Basics)".)

Fish — The American Academy of Pediatrics recommends that nursing mothers take in 200 to 300 mg of omega-3 fatty acids per day [1]. Women can meet this need with one to two servings of fish per week, such as herring, canned light tuna, or salmon. To reduce exposure to mercury, mothers should avoid predatory fish such as shark, swordfish, king mackerel, or tilefish, which have high levels of mercury.

Check local advisories about the safety of fish caught by family and friends in local lakes, rivers, and coastal areas (www.epa.gov/waterscience/fish/). If no advice is available, breastfeeding mothers may eat up to 6 ounces (one average meal) per week of fish caught from local waters, but should not consume any other fish during that week.

MEDICATION SAFETY WITH BREASTFEEDING

Most medications taken by mothers during breastfeeding are safe for their infants. However, there are exceptions. For this reason, it is best to consult with a healthcare provider, lactation consultant, or pharmacist if there is any question of a medication's safety while breastfeeding [2]. It is important to be aware that the quality of information regarding medication safety in breastfeeding varies [3]. The LactMed database, which is maintained by the National Library of Medicine, is a reliable source of up-to-date information about which medications are compatible with breastfeeding (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT).

Some medications are safe but can potentially affect the amount of breast milk produced. For example, combined estrogen/progesterone birth control pills may decrease the amount of milk a woman produces, but the effect varies among women. In some cases it may be best to avoid this type of birth control pill. Progesterone-only birth control pills, intrauterine devices (IUDs), and injections are less likely to affect milk supply, although early placement of progesterone-containing IUDs has been reported to decrease breastfeeding duration [4]. Copper IUDs provide long-acting, reversible contraception without any hormones, and may be preferable for breastfeeding mothers. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)      

Over-the-counter decongestants that contain pseudoephedrine (Sudafed) can also decrease milk supply [5].

Medications to avoid while breastfeeding — Some medications are known to be harmful to infants and should be avoided by women who breastfeed if possible. Illegal drugs such as amphetamines, cocaine, phencyclidine (PCP), and heroin are not safe for a woman or her baby; women who use these drugs are advised to not breastfeed. There are limited data on the effects of marijuana in infants; we advise women who breastfeed to avoid use of marijuana.

Alcohol — When a breastfeeding woman consumes alcohol, a small percentage of alcohol is transferred into her breast milk; however, when the alcohol is cleared from her bloodstream, it is also cleared from her milk. The amount of alcohol considered to be "safe" while breastfeeding is controversial. A number of factors affect how much alcohol is transferred to breast milk and how much an infant absorbs.

For an average-weight woman, it takes about two hours for a single serving of alcohol to clear completely from her body. One serving of alcohol is 12 ounces of beer, five ounces of wine, or 1.5 ounces of 80-proof liquor. To completely avoid any alcohol being transferred to the infant, experts recommend that a woman wait about two hours after consuming a single serving of alcohol. It is not necessary for her to express and discard her milk if she has waited two hours. If a woman drinks more than this amount, she should refrain from breastfeeding for an additional two hours for each serving of alcohol [6].

Caffeine — Most breastfeeding women can drink a moderate amount caffeine without it affecting their infants. The American Academy of Pediatrics defines a moderate intake of caffeine as two to three cups of a caffeinated beverage per day [2]. However, some young infants are sensitive to caffeine and become irritable or have difficulty sleeping, even with small amounts of caffeine. An infant's sensitivity to caffeine usually lessens over time because caffeine clearance is initially slow in newborns, but rises to adult clearance levels by three to five months.

Tobacco — Infants of parents who smoke have an increased risk of a number of conditions, including asthma, pneumonia, ear infections, bronchitis, and sudden infant death syndrome (SIDS), among others. These risks also apply to infants who are breastfed and live with smokers. Cutting down or stopping smoking can decrease these risks. However, for women who are unable to stop smoking, evidence suggests that the benefits of breastfeeding outweigh the risks of formula feeding. Smoking can reduce a mother's milk supply. (See "Patient education: Quitting smoking (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Health and nutrition for women who breastfeed (The Basics)
Patient education: Nutrition before and during pregnancy (The Basics)
Patient education: Breastfeeding (The Basics)
Patient education: Common breastfeeding problems (The Basics)
Patient education: Vitamin B12 deficiency and folate (folic acid) deficiency (The Basics)
Patient education: Vitamin supplements (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Diet and health (Beyond the Basics)
Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Breastfeeding guide (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Pumping breast milk (Beyond the Basics)
Patient education: Calcium and vitamin D for bone health (Beyond the Basics)
Patient education: Anemia caused by low iron in adults (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Breastfeeding: Parental education and support
Common problems of breastfeeding and weaning
Maternal nutrition during lactation
Nutrition in pregnancy
Nutritional composition of human milk for full-term infants
The impact of breastfeeding on the development of allergic disease
Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding
Treatment, prognosis, and prevention of Listeria monocytogenes infection
Prevention of HIV transmission during breastfeeding in resource-limited settings

The following organizations also provide reliable health information.

National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

LactMed – For information about which medications are compatible with breastfeeding

(http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT)

The Academy of Breastfeeding Medicine

(www.bfmed.org)

La Leche League

(www.lalecheleague.org)

The Center for Disease Control and Prevention

(www.cdc.gov/breastfeeding)

American Academy of Pediatrics

(www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/default.aspx)

International Board of Lactation Consultant Examiners

(www.iblce.org)

phone: 703-560-7330

International Lactation Consultant Association

(www.ilca.org)

phone: 919-861-5577

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Literature review current through: Nov 2016. | This topic last updated: Tue Nov 08 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
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  1. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129:e827.
  2. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001; 108:776.
  3. Akus M, Bartick M. Lactation safety recommendations and reliability compared in 10 medication resources. Ann Pharmacother 2007; 41:1352.
  4. Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration. Contraception 2011; 84:499.
  5. Aljazaf K, Hale TW, Ilett KF, et al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol 2003; 56:18.
  6. Ho E, Collantes A, Kapur BM, et al. Alcohol and breast feeding: calculation of time to zero level in milk. Biol Neonate 2001; 80:219.
  7. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes IoM. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline, National Academy Press, Washington, DC 2000.
  8. What about drinking alcohol and breastfeeding? La Leche League. Available at: www.lalecheleague.org/FAQ/alcohol.html (Accessed on September 12, 2016).
  9. Food and Nutrition Board and Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements, Otten J, Hellwig JP, Meyers LD (Eds), National Academies Press, Washington, DC 2006.
  10. Lopez LM, Grey TW, Stuebe AM, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev 2015; :CD003988.
  11. American College of Obstetricians and Gynecologists' Committee on Obstetric Practice, Breastfeeding Expert Work Group. Committee Opinion No. 658: Optimizing Support for Breastfeeding as Part of Obstetric Practice. Obstet Gynecol 2016; 127:e86.
  12. Lovelady C. Balancing exercise and food intake with lactation to promote post-partum weight loss. Proc Nutr Soc 2011; 70:181.

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.