BREASTFEEDING AND HEALTH OVERVIEW

Women have an amazing ability to produce a sufficient quantity and quality of breastmilk to support an infant, even if the woman is malnourished. However, breastfeeding women do need an increased number of calories and nutrients to maintain their milk supply.

In most cases, the best way to get an adequate number of 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 information: Diet and health".)

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 information: Common breastfeeding problems" and "Patient information: Breastfeeding basics" and "Patient information: Deciding to breastfeed" and "Patient information: Breast pumps".)

NUTRITION AND BREASTFEEDING

Calorie recommendations — The total number of calories a woman needs depends upon the following factors:

• Weight
• Age
• Height
• Activity level

For example, a 25-year-old woman who is not breastfeeding and is 5 feet, 5 inches tall and 140 pounds and is not active needs approximately 2190 calories per day. A woman who is older, shorter, who weighs less or who is less active would need fewer calories per day while a woman who is taller, younger, weighs more, or is more active would need more calories per day.

The energy and nutritional requirements of women who breastfeed are greater than that of women who are not breastfeeding. Thus, women who breastfeed exclusively usually need an additional 500 calories per day to maintain their weight. Using the woman in the above example, the recommended total calorie intake would be approximately 2690 calories per day.

Fluid intake — The average woman who breastfeeds exclusively produces 750 to 800 mL (approximately 25 ounces) 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 cup of water or another non-caffeinated beverage nearby while nursing or working.

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 breastmilk. This is true even for women who diet for long periods of time. However, a breastfeeding woman should consume at least 1500 calories per day to avoid excessive weight loss, which could decrease the breast milk quantity and quality.

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 (eg, vegans) usually 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. This loss cannot be prevented by consuming additional calcium during pregnancy or while breastfeeding. However, lost bone is usually regained after a woman stops 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 1). A simple way to estimate one's daily intake of dietary calcium is to multiply the number of dairy servings consumed each day by 300 mg. One serving equals 8 oz of milk or yogurt, 1 oz of hard cheese, 12 oz of cottage cheese, or 2 cups of broccoli.

If it is not possible to consume enough milk or other foods that contain calcium, it is reasonable to take a calcium supplement (table 2). Calcium supplements should be taken in divided doses, two to three times per day. (See "Patient information: Calcium and vitamin D for bone health".)

Vitamin D — Absorption of calcium depends upon having an adequate level of vitamin D. Both breastfeeding and non-breastfeeding women require at least 200 IU (5 micrograms) per day of vitamin D when sunlight is inadequate; in many areas of the United States, there is inadequate sunlight during the fall, winter, and early spring months [1]. Milk is the best source of dietary vitamin D, with approximately 100 IU per cup. A vitamin D or calcium plus vitamin D supplement are also good sources of vitamin D.

Iron — Women who are not anemic after delivery and who breastfeed exclusively do not usually have a menstrual period for the first four to six months. Thus, there is little iron lost in menstrual blood. An iron supplement is not usually needed during this time.

Women who are anemic after delivery usually require an iron supplement; this may include an over-the-counter or prescription iron supplement. The recommended type and dose of iron should be discussed with a healthcare provider. (See "Patient information: Iron deficiency anemia".)

FOODS TO LIMIT OR AVOID WHILE BREASTFEEDING

Some foods and drinks should be avoided or consumed in limited quantities while breastfeeding.

Fish — Some fish have high levels of methylmercury, a type of mercury. High levels of mercury in the blood can be harmful to a child's developing nervous system. The United States Food and Drug Administration (FDA) and Environmental Protection Agency (EPA) recommend that pregnant and breastfeeding women should [2,3]:

• Avoid eating any shark, swordfish, king mackerel, or tilefish. These fish have high levels of mercury.
• Breastfeeding mothers can eat up to 12 ounces a week (2 average servings) of fish and shellfish that have lower concentrations of mercury. This includes shrimp, canned light tuna, salmon, pollock, and catfish. Albacore (white) tuna has more mercury than canned light tuna, and should be limited to 6 ounces (one average meal) per week.
• 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 do not consume any other fish during that week.

Foods that are safe — Some foods, such as deli meats, soft cheeses, refrigerated meat spreads, and other items are not recommended during pregnancy due to the risk of ingesting a bacteria known as listeria. Listeria can cause a mild illness in adults and a serious or life-threatening infection in infants who are infected during pregnancy. However, women who are breastfeeding do not need to avoid or limit these foods; listeria cannot be passed through breastmilk.

MEDICATION SAFETY WITH BREASTFEEDING

In general, medications that are safe during pregnancy are also safe while breastfeeding. 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 [4]. It is important to be aware that the quality of information regarding medication safety in breastfeeding varies [5]. A reliable source of up-to-date information is LactMed, which is available from the National Library of Medicine (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT).

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.

Medications that are safe — Some prescription and non-prescription medications that are not recommended during pregnancy are safe to use while breastfeeding.

Some medications are safe but can potentially affect the amount of breastmilk produced. For example, combined estrogen/progesterone birth control pills may decrease the amount of milk a woman produces. For this reason, women who are breastfeeding are discouraged from using combination birth control pills. Progesterone-only birth control pills, IUDs, and injections are not thought to affect milk supply. (See "Patient information: Hormonal methods of birth control".)

Alcohol — When a breastfeeding woman consumes alcohol, a small percentage of alcohol is transferred into her breastmilk. The amount of alcohol considered to be "safe" while breastfeeding is controversial. A number of factors affect how much alcohol is transferred to breastmilk and how much an infant absorbs.

For an average-weight women, 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 two hours after consuming a single serving of alcohol. If a woman drinks more than this amount, she should refrain from breastfeeding for an additional two hours for each serving of alcohol [6].

Other sources have suggested that women should drink no more than one serving of alcohol while breastfeeding [5,6]. It is not necessary to discard breast milk (eg, "pump and dump") after consuming alcohol because the alcohol will leave the mother's milk as the body clears it over a few hours.

Caffeine — Most breastfeeding women can drink a moderate amount caffeine without it affecting their infant. The American Academy of Pediatrics defines a moderate intake of caffeine as two to three cups of a caffeinated beverage per day [4]. 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.

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 exist among infants who live with smokers, even if the mother breastfeeds. Cutting down or stopping smoking can decrease these risks. However, women who smoke are still encouraged to breastfeed. (See "Patient information: Quitting smoking".)

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 every four months 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

Patient information: Diet and health
Patient information: Common breastfeeding problems
Patient information: Breastfeeding basics
Patient information: Deciding to breastfeed
Patient information: Breast pumps
Patient information: Calcium and vitamin D for bone health
Patient information: Iron deficiency anemia
Patient information: Hormonal methods of birth control
Patient information: Quitting smoking

Professional level information

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
Principles of medication use during lactation
The impact of breastfeeding on the development of allergic disease
Transmission of HIV through breastfeeding: Risk factors and prevention
Use of psychotropic medications in breastfeeding women

The following organizations also provide reliable health information.

• National Library of Medicine

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

• LactMed

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

• La Leche League

      (www.lalecheleague.org)

• The Center for Disease Control and Prevention

      (www.cdc.gov/breastfeeding)

• The United States Department of Health and Human Services

      (www.womenshealth.gov/Breastfeeding)

• American Academy of Pediatrics

      (www.aap.org/healthtopics/breastfeeding.cfm)

• International Board of Lactation Consultant Examiners

      (www.iblce.com)

      phone: 703-560-7330

• International Lactation Consultant Association

      (www.ilca.org)

      phone: 919-861-5577

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