The Vegetarian Breastfeeding Mothers


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A collaborative of web resources of the vegetarian breastfeeding mothers. Targeting on diets plan during breastfeeding. Nutrients deficiency to a child and more insights.

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The Vegetarian Breastfeeding Mothers

  1. 1. The Vegetarian Breastfeeding Mother Collaborate by Karen Ho, dated 16 August 2013
  2. 2. INDEX 2. Vitamin B12 and Vegetarian Diets • Vitamin B12 Deficiency • Digestion and absorption of Vitamin B12 • Vegetarians and Vitamin B12 status • Vegetarians infants and Vitamin B12 status • Vitamin B12 in the vegetarian diets • Vegetarian meal plan and food sources 1. Know Your Option. Know Your Right • Traditional After-Birth Care Theory and Nutrition • Case Study Valerie Lynn Post Pregnancy Wellness Coach Collaborate and prepare by Karen Ho, Interaction Designer, IT Medical Journal of Australia 3. A balanced vegetarian diest supports healthy breasfeeding • Calories Needs and Weigh Loss • High calorie, high nutrient foods • Fluids Needs • Meal plannning guidelines for breastfeeding vegetarians • Important nutrients Vegetarian Diets During Lactation
  3. 3. INDEX 5. The Vegetarian Breastfeeding Mothers • Vegan and Types of Vegan • Breastfeeding Mothers on vegan diets 4. Healthy eating for vegan pregnant and breastfeeding mothers Queensland Dietitians Last reviewed: June 2013 Leaders, USA 6. A balanced vegetarian diest supports healthy breasfeeding • Infants Formulas • Formula Milk and Soya Milk • The Best Diets for Breastfeeding • Weigh Loss and Milk Loss • Protein Requirement Vegan Baby and Children The Vegan Society 7. Breastfeeding Mothers and Fenugreek Breastfeeding and Herbs Collaborate and prepare by Karen Ho, Interaction Designer, IT
  4. 4. INDEX 9. Prenatal and Postnatal Care, Feeding and Dietary 8. Nutrient Adequacy of Exclusive Breastfeeding for the Term Infant During the First Six Month of Life World Health Organization Geneva WHO 2002 Pre-Post Natal Care 10. How much milk do my baby need? Estimating and Calculation of Expressed Milk Collaborate and prepare by Karen Ho, Interaction Designer, IT
  5. 5. Know your option, know your right Traditional After-Birth Care Theory and Nutrition By Choicesinchildbirth Valerie Lynn is American’s first Post-pregnancy Well- ness Coach and founder of the Post-pregnancy Well- ness Company. She is introducing an entirely new paradigm regard- ing after birth care in the United States based on Eastern influences. Her book, The Mommy Plan, Re- storing Your Post-pregnancy Body Naturally Using Women’s Tradi- tional Wisdom, is gaining global recognition in the child birth industry as she has explained core tenants of traditional after birth guidelines surrounding a mother’s diet, activities and personal care during the first 6-8 weeks after child birth. Valerie is the International Country Co- ordinator of Malaysia, for Postpartum Support International (PSI); and is on the Board of Advisors for the After Birth Project, a documentary- in-the-making on the lack of after birth support in the United States and the social effects. Valerie is the first foreigner, in Malaysia, to be university strained in traditional after birth care and is a practicing Tra- ditional Postpartum Practitioner. She offers training in traditional after birth care, herbal body treatments, massage and abdominal wrapping, and is the Sole US distributor of a unique traditional Postnatal Care Set. Resources: By Valerie Lynn, Author, The Mommy Plan This entry was posted on March 7, 2013 at 3:06 pm and is filed under Postpartum Health Website URL:
  6. 6. Know your option, know your right Traditional After-Birth Care Theory and Nutrition By Choicesinchildbirth Case Study: By Valerie Lynn, Author, The Mommy Plan In May 2007, I returned to the U.S. after living in Asia for ten years. That same month, I gave birth to my son, Jordan. I quickly realized that in the United States specific, structured care for mothers after delivery didn’t exist – and still doesn’t today. I’ve asked myself why this is the case many times over the years. Care during the first six weeks post-natally is deemed as a crucial healing period to at least three billion people around the globe. Why is this period not deemed as equally important in my own country, where we have at least 4 million births per year? I at- tribute this to the medicalization of birth and the diminished role of the midwife, beginning in the early 1900s. Our heritage of after-birth care has been lost. There is no longer an understanding of the transition of a woman’s body back to a non-pregnant state and the intense healing pro- cess that goes on in those first few weeks. The Humoral Theory of Medicine All after-birth traditions, practices, and guidelines are based on one of the oldest scientific theories in the world, the Humoral Theory of Medi- cine. According to this ancient theory, there are four conditions in the human body: hot, cold, moist, and dry, and they must remain in balance. The Humoral Theory of Pregnancy states that a woman’s body is out of balance and in a hot state while pregnant, as her body primarily func- tions as an incubator to support a growing and developing baby. The hot state is due to additional sources of heat, such as: raised level of hor- mones, baby’s body heat, the placenta and amniotic fluid, as well as a 50% increase in the volume of blood. All of these factors combine to raise a mother’s body temperature throughout pregnancy by 1-1.5°F. In fact, the first scientific pregnancy test was an elevated temperature for two weeks outside of the menstruation period. When a baby is born, a mother’s body temperature drops the same amount, 1-1.5°F below the normal body temperature. The decrease is due to the loss of heat sources, namely the baby’s body heat, the pla- centa, amniotic fluid, and blood, along with exhaustion from labor. At this time the mother’s body shifts into a cold state and the Humoral Theory of Medicine can be applied to the post-pregnancy period, when the body is again out of balance.
  7. 7. Know your option, know your right Traditional After-Birth Care Theory and Nutrition By Choicesinchildbirth Case Study: By Valerie Lynn, Author, The Mommy Plan Sustaining & Raising Body Temperature Traditional post-pregnancy recovery guidelines emphasize the impor- tance of raising a mother’s internal body temperature at a consistent pace over the six weeks after delivery. Therefore, all guidelines sur- rounding a mother’s diet and beverage intake, personal care, and activ- ity during this time are based on the notion that, due to the mother’s body being in a cold state, the remaining heat must be protected and maintained, ensuring no body heat escapes. In addition, a post-baby body has specific nutritional and energetic temperament needs than when it was in a pregnant state, which can be met by consuming nutrient dense healing foods. Heaty foods are Healing Foods A traditional after birth diet, whether from Asia, Latin America or else- where, is one where food is used as medicine to help accelerate the body’s natural healing capabilities. Since a mama’s body is in a cold state after delivery, only heaty foods should be consumed. The word ‘heaty’ refers to the capacity of a particular food, herb or spice to gener- ate a “hot sensation” and warming within the body. This is not to be con- fused with food being overly spicy, a taste sensation that provides a sharp spicy taste and causes sweating. That sort of heat is not good for a mama’s recovering body. Foods deemed as having a cold temperament should not be consumed during the healing period after delivery, as this may delay the natural in- crease in body temperature and shock the body’s digestive system. In turn, this could interrupt the healing process, lower body temperature further, and prolong the recovery process. Most vegetables are considered to have a cold temperament and theo- retically shouldn’t be consumed at this time. However, the coldness may be counteracted by the way the vegetables are prepared. For example, adding fresh ginger root while cooking makes vegetables “warm,” thus acceptable to eat and good for recuperation. A nutritious, wholesome, and natural diet should always be encouraged. However, even good foods can be trouble for the digestive system during the immediate post-pregnancy period due to the unique state of a mama’s body after delivery.
  8. 8. Know your option, know your right Traditional After-Birth Care Theory and Nutrition By Choicesinchildbirth Case Study: By Valerie Lynn, Author, The Mommy Plan Some of the traditional foods to avoid are nutritious and healthy such as broccoli, tomatoes and cauliflower. Please take note that it is only during the post-birth recovery period, when the body is in a weakened state, that specific foods should be avoided; by no means are they per- manent recommendations. Post-pregnancy Dietary Plan After childbirth you should continue to eat well. One hour after the pla- centa is birthed the body begins its transition back to a non-pregnant state. Over the first six weeks postpartum a mama’s body goes through an intense internal workout as a significant amount of healing takes place. Pregnancy is approximately 259 – 280 days or 37-40 weeks, and in just 42 days or six weeks, (medically speaking) the physical shrink- age of the perinatal organs is back to normal and most of the loss of re- tained water, fat, and gas takes place. This healing time equates to 15% of the total amount of time spent in a pregnant state. With this in mind, don’t you think a post-pregnancy dietary plan is just as important as a dietary plan during pregnancy? Three billion people around the globe do. By avoiding foods that interfere with the healing process you allow your body to have a stronger and more balanced recovery in a shorter period of time. Don’t Underestimate Traditional Post-Pregnancy Care The childbirth industry is in transition as more mothers are searching for ways to help speed up their recovery after childbirth. The United States is one of only four countries in the world that does not require employ- ers to provide paid maternity care. Women therefore need to return to work as soon as they are able. Western countries are no longer under- estimating the effectiveness of traditional post-pregnancy care, but trying to understand them. As women across the world are embracing more natural products and services into their lifestyles, western mamas are searching for natural ways to recover from childbirth. Post-pregnan- cy care that facilitates healing at a faster rate is becoming increasingly valued in modern cultures where women must resume their normal lives within weeks after delivery.
  9. 9. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 1/11 Advanced Search Clinical focus Vitamin B12 and vegetarian diets Carol L Zeuschner, Bevan D Hokin, Kate A Marsh, Angela V Saunders, Michelle A Reid and Melinda R Ramsay MJA Open 2012; 1 Suppl 2: 27-32. doi:10.5694/mjao11.11509 Abstract Vitamin B12 is found almost exclusively in animal-based foods and is therefore a nutrient of potential concern for those following a vegetarian or vegan diet. Vegans, and anyone who significantly limits intake of animal-based foods, require vitamin B12-fortified foods or supplements. Vitamin B12 deficiency has several stages and may be present even if a person does not have anaemia. Anyone following a vegan or vegetarian diet should have their vitamin B12 status regularly assessed to identify a potential problem. A useful process for assessing vitamin B12 status in clinical practice is the combination of taking a diet history, testing serum vitamin B12 level and testing homocysteine, holotranscobalamin II or methylmalonic acid serum levels. Pregnant and lactating vegan or vegetarian women should ensure an adequate intake of vitamin B12 to provide for their developing baby. In people who can absorb vitamin B12, small amounts (in line with the recommended dietary intake) and frequent (daily) doses appear to be more effective than infrequent large doses, including intramuscular injections. Fortification of a wider range of foods products with vitamin B12, particularly foods commonly consumed by vegetarians, is likely to be beneficial, and the feasibility of this should be explored by relevant food authorities. Vitamin B12 (cobalamin) is an essential vitamin, required for DNA synthesis (and ultimately cell division) and for maintaining nerve myelin integrity. It is found almost exclusively in animal-based products including red meats, poultry, seafood, milk, cheese and eggs. As vitamin B12 is produced by bacteria in the large intestines of animals, plant-based foods are generally not a source of vitamin B12. It is therefore a nutrient of concern for vegetarians and particularly for vegans who choose an entirely plant-based diet. A cross-sectional analysis study involving 689 men found that more than half of vegans and 7% of vegetarians were deficient in vitamin B12. Vitamin B12 deficiency Vitamin B12 deficiency is a serious health problem that can result in megaloblastic anaemia, inhibition of cell division, and neurological disorders. Folate deficiency can also cause megaloblastic anaemia and, although a high folate intake may correct anaemia from a vitamin B12 deficiency, subtle neurological symptoms driven by the vitamin B12 deficiency may arise. Loss of intrinsic factor, gastric acid or other protein-digesting enzymes contributes to 95% of known cases of vitamin B12 deficiency. Other factors that may contribute to vitamin B12 deficiency are listed in Box 1. However, in vegetarian and vegan populations, dietary insufficiency is the major cause. Furthermore, high levels of folate can mask vitamin B12 deficiency — a concern for vegetarians and vegans whose folate intake is generally high while vitamin B12 intake is low. The addition of vitamin B12 to any foods fortified with folate has been advocated to prevent masking of haematological and neurological manifestations of vitamin B12 deficiency. Subtle neurological damage (even in the absence of anaemia) may be more likely in vegans because of their increased folate levels preventing early detection of vitamin B12 deficiency. Vitamin B12 deficiency can also lead to demyelinisation of peripheral nerves, the spinal cord, cranial nerves and the brain, resulting in nerve damage and neuropsychiatric abnormalities. Neurological symptoms of vitamin B12 deficiency include numbness and tingling of the hands and feet, decreased sensation, difficulties walking, loss of bowel and bladder control, memory loss, dementia, depression, general weakness and psychosis. Unless detected and treated early, these symptoms can be irreversible. 1 2 3 4 13 4 14 4 3,4
  10. 10. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 2/11 Digestion and absorption of vitamin B12 The digestion of vitamin B12 begins in the stomach, where gastric secretions and proteases split vitamin B12 from peptides. Vitamin B12 is then free to bind to R-factor found in saliva. Pancreatic secretions partially degrade the R-factor, and vitamin B12 is then bound to intrinsic factor. Intrinsic factor binds to the ileal brush border and facilitates the absorption of vitamin B12. Box 2 illustrates the process of vitamin B12 digestion and absorption. Vitamin B12 absorption may decrease if intrinsic factor production decreases. There are many well documented factors causing protein-bound vitamin B12 malabsorption, including gastric resection, atrophic gastritis, and the use of medications that suppress acid secretion (see Box 1). Up to 89% of vitamin B12 consumed in the diet is absorbed, although as little as 9% is absorbed from some foods (including eggs). This relatively high rate of absorption, combined with low daily requirements and the body’s extremely efficient enterohepatic circulation of vitamin B12, contributes to the long period, often years, for a deficiency to become evident. Studies have been inconsistent in linking the duration of following an unsupplemented vegan diet with low serum levels of vitamin B12. Intestinal absorption is estimated to be saturated at about 1.5–2.0 µg per meal, and bioavailability significantly decreases as intake increases. Ageing causes a decreased level of proteases, as well as a reduced level of acid in the stomach. As a result, vitamin B12 is less effectively removed from the food proteins to which it is attached, and food-bound vitamin B12 absorption is diminished. The Framingham Offspring Study found that the vitamin B12 from supplements and fortified foods may be more efficiently absorbed than that from meat, fish and poultry. While low vitamin B12 status in vegetarians and vegans is predominantly due to inadequate intake, some cases of pernicious anaemia are attributable to inadequate production of intrinsic factor. Under the law of mass action, about 1% of vitamin B12 from large oral doses can be absorbed across the intestinal wall, even in the absence of adequate intrinsic factor. Assessing vitamin B12 status Taking a simple diet history can be a useful indicator of vitamin B12 intake and adequacy. However, laboratory analyses provide a much more accurate assessment. Measurement of serum vitamin B12 levels is a common and low-cost method of assessing vitamin B12 status. The earlier method of measuring vitamin B12 using biological assays was unreliable, as both the active and inactive analogues of vitamin B12 were detected, so levels were often overestimated. Modern radio isotope and immunoassay methods reliably measure biologically available analogues of vitamin B12. The early measured ranges of acceptable levels of serum vitamin B12 were determined using individuals who were apparently healthy but had potentially marginal levels of vitamin B12. This has resulted in reference intervals probably being set too low to provide a reliable clinical decision. To improve the ability to predict marginal vitamin B12 status, a higher reference interval (> 360 pmol/L) has been proposed. Objective measures of neurological damage have been found in patients with vitamin B12 levels below 258 pmol/L. However, the usual reference interval for vitamin B12 deficiency is < 220 pmol/L. Achieving national and international agreement on the definition of serum vitamin B12 deficiency would provide some clarity for comparison of studies and reduce variability in defining those at risk of deficiency. Internationally, the cut-off for vitamin B12 varies markedly between < 130 pmol/L and < 258 pmol/L. Serum vitamin B12 levels alone do not provide a measure of a person’s reserves of the vitamin. It is recommended that a metabolic marker of vitamin B12 reserves, such as serum homocysteine, also be determined. Elevated homocysteine levels can be a useful indicator for vitamin B12 deficiency, because serum homocysteine levels increase as vitamin B12 stores fall. While serum homocysteine levels greater than 9 µmol/L suggest the beginning of depleted vitamin B12 reserves, standard laboratory reference intervals suggest levels greater than 15 µmol/L as a marker for depleted vitamin B12 reserves. Although homocysteine levels may also increase with folate or vitamin B6 deficiency, these deficiencies are likely to be rare in vegetarians and vegans. Other markers for vitamin B12 deficiency include serum holotranscobalamin II (TC2) and urinary or serum methylmalonic acid (MMA). TC2 is the protein that transports vitamin B12 in blood, and its levels fall in vitamin B12 deficiency. Testing for this carrier protein can identify low vitamin B12 status before total serum vitamin B12 levels drop. Vitamin B12 is the only coenzyme required in the conversion of methylmalonyl-CoA to succinyl-CoA, so methylmalonyl-CoA levels increase with vitamin B12 deficiency. As it is toxic, methylmalonyl-CoA is converted to MMA, which accumulates in the blood and is excreted in the urine, enabling either urinary or serum MMA to be a useful measure of vitamin B12 reserves. Because TC2 15 17,18 2,19 18 4 20 21 17 4,22 23 24 25 Need website help? Contact us now!
  11. 11. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 3/11 is one of the earliest markers of vitamin B12 deficiency, it may be one of the better means of assessing vitamin B12 status. Requirements Box 3 shows the vitamin B12 nutrient reference values for Australia and New Zealand. As no recommended dietary intakes (RDIs) are available for infants under 12 months of age, an adequate intake is recommended instead. Vegans at all stages of the life cycle need to ensure an adequate and reliable source of vitamin B12 from fortified foods, or they will require supplementation equivalent to the RDI. Vegetarians and vitamin B12 status While reported cases of frank vitamin B12 deficiency in vegetarians or vegans are rare, several studies have found lower vitamin B12 levels in vegans and vegetarians compared with the general population. The European Prospective Investigation into Cancer and Nutrition (EPIC)-Oxford cohort study found that 121 of 232 vegans (52%), 16 of 231 vegetarians (7%) and one of 226 omnivores (0.4%) were classed as vitamin B12-deficient. There was no significant association between age or duration of subjects’ adherence to a vegetarian or vegan diet and the serum levels of vitamin B12. Intuitively, it is assumed that prevalence of deficiency increases with a longer duration of vegetarian diet. Although it can take years for deficiency to occur, it is likely that all vegans and anyone who does not regularly consume animal- based foods, and whose diets are unsupplemented or unfortified, will eventually develop vitamin B12 deficiency. Vegetarians and vegans should have their vitamin B12 status regularly assessed to enable early intervention if levels fall too low. Vegetarian infants and vitamin B12 status The risk of a breastfed infant becoming deficient in vitamin B12 depends on three factors: the vitamin B12 status of the mother during pregnancy; the vitamin B12 stores of the infant at birth; and the vitamin B12 status of the breastfeeding mother. The fetus obtains its initial store of vitamin B12 via the placenta, with newly absorbed vitamin B12 (rather than maternal stores) being readily transported across the placenta. Under normal conditions, full-term infants will have enough stored vitamin B12 at birth to last for about 3 months when the maternal diet does not contain vitamin B12. An infant born to a vegetarian or vegan mother is at high risk of deficiency if the mother’s vitamin B12 intake is inadequate and her stores are low. Vegetarian women who have repeated pregnancies place infants at greater risk, because their vitamin B12 stores are likely to have been depleted by earlier pregnancies. Vegetarian or vegan women must have a balanced diet, including adequate intake of vitamin B12, to provide for their babies during both pregnancy and lactation. Recent studies suggest that maternal stores of vitamin B12 are also reflected in breastmilk. When maternal serum vitamin B12 levels are low, vitamin B12 levels in breastmilk will also be low, and the infant will not receive an adequate vitamin B12 intake. There have been reports of deficiency in the breastfed infants of vegan (or “strict vegetarian”) mothers who did not supplement their diets with vitamin B12, because of the smaller stores of vitamin B12 gained by the infant during pregnancy and the low vitamin B12 content of breastmilk (reflective of the mothers’ serum levels). Infants have presented with a range of symptoms, often initially signalled by developmental delay. Lack of vitamin B12 in the maternal diet during pregnancy has been shown to cause severe retardation of myelination in the nervous system of the infant. Visible signs of vitamin B12 deficiency in infants may include involuntary motor movements, dystrophy, weakness, muscular atrophy, loss of tendon reflexes, psychomotor regression, cerebral atrophy, hypotonia and haematological abnormalities. While supplementation with vitamin B12 results in rapid improvements in laboratory measures of vitamin B12 status, there is continuing research about the long-term effects of deficiency in infants. Vitamin B12 in the vegetarian diet Lacto-ovo-vegetarians will have a reliable source of vitamin B12 in their diet, provided they consume adequate amounts of dairy products and eggs, although their intake is likely to be lower than in meat eaters. However, those who follow a vegan diet will not have a reliable intake unless they consume foods fortified with vitamin B12 or take a supplement. It was once thought that some plant foods, such as spirulina, and fermented soy products, including tempeh and miso, were dietary sources of vitamin B12, but this has been proven incorrect. Recent research has found traces of vitamin B12 in white button mushrooms and Korean purple laver (nori), but the quantity in a typical serving means that they are not a significant dietary source of this vitamin. An average serving of mushrooms contains about 5% of the RDI, making the quantity required to supply adequate amounts of vitamin B12 to vegetarians impractical. Further, use of 22 26 27,28 2 2 29 30 31 32 33,34 35 36 37,38 37 39 40 41 40,41
  12. 12. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 4/11 Korean laver is unlikely to be widespread in the Australian diet. With the unique exception of these two plant foods, any vitamin B12 detected in other plant foods is likely to be the inactive analogue, which is of no use to the body and can actually interfere with the absorption of the active form. Box 4 shows a sample vegetarian meal plan for a 19–50-year-old woman, which includes food sources typical in a Western-style diet and meets the RDI of vitamin B12 and requirements for other key nutrients (except vitamin D and long- chain omega-3 fatty acids). Excluding or limiting dairy foods or fortified soy milk from the vegetarian diet would necessitate the need for vitamin B12 supplements. Fortified foods In contrast to the United States, where foods are extensively fortified with vitamin B12, Food Standards Australia New Zealand permits only a limited number of foods to be fortified with vitamin B12. This includes selected soy milks, yeast spread, and vegetarian meat analogues such as soy-based burgers and sausages. Examples of the vitamin B12 content of foods suitable for vegetarians are shown in Box 5. Vitamin B12 added to foods is highly bioavailable, especially in people with vitamin B12 deficiency caused by inadequate dietary intake. An unpublished Australian study (Hokin BD. Vitamin B12 deficiency issues in selected at-risk populations [PhD thesis]. Newcastle: University of Newcastle, 2003) compared the effectiveness of fortified soy milk (two servings of 250 mL/day), soy-based meat analogues (one serving/day), vitamin B12 supplements (one low-dose tablet/day or one high-dose tablet/week) and vitamin B12 intramuscular injections (one injection/month) in raising serum vitamin B12 levels in subjects with deficiency. The study found that fortified foods were superior to the traditional methods of supplementation (intramuscular injections and tablets). Further research would be beneficial to confirm these findings. With inadequate dietary intake being a risk for vegetarians and vegans, further fortification of foods commonly consumed by this population with vitamin B12 would be beneficial and should be considered by the relevant authorities. Supplements In a vegan diet, using a supplement or consuming fortified foods is the only way to obtain vitamin B12. As the body can only absorb a limited amount of vitamin B12 at any one time, it is better to take small doses more often, instead of large doses less often. One study found that small doses of vitamin B12 in the range of 0.1–0.5 µg resulted in absorption ranging between 52% and 97%; doses of 1 µg and 5 µg resulted in mean absorption of 56% and 28%, respectively, while higher doses had even lower absorption, with 10 µg and 50 µg doses resulting in 16% and 3%, respectively, being absorbed. While sublingual supplements are often promoted as being more efficiently absorbed, there is no evidence to show that this form of supplement is superior to regular oral vitamin B12. Vitamin B12 supplements are not made from animal-based products and are suitable for inclusion in a vegan diet. Conclusion Vitamin B12 deficiency is a potential concern for anyone with insufficient dietary intake of vitamin B12, including those adhering to a vegan or vegetarian diet or significantly restricting animal-based foods. Studies have found that vegetarians, particularly vegans, have lower serum vitamin B12 levels, and it is likely that anyone avoiding animal-based foods will eventually become deficient if their diet is not supplemented. All vegans, and lacto-ovo-vegetarians who don’t consume adequate amounts of dairy products or eggs to provide sufficient vitamin B12, should therefore supplement their diet with vitamin B12 from fortified foods or supplements. It is particularly important that pregnant or breastfeeding vegan and vegetarian women consume a reliable source of vitamin B12 to reduce the risk of their baby developing a vitamin B12 deficiency. 40,41 42 17 44 Box 1 – Causes of vitamin B12 deficiency, with contributing factors (#) Inadequate dietary intake Restrictive diet or dieting; vegetarian or vegan diets without supplementation or use of fortified foods Inadequate absorption or impaired utilisation Loss of intrinsic factor, loss of gastric acid and/or other protein-digesting enzymes (contributes to 95% of known cases) Use of medications that suppress acid secretion, including somatostatin, cholecystokinin, atrial natriuretic peptide, 4 5
  13. 13. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 5/11 and nitric oxide Pancreatic disease Gastric resection, sleeve or banding surgery Ileal disease or ileal resection (secondary to Crohn’s disease) Use of metformin (oral hypoglycaemic agent) Use of angiotensin-converting enzyme inhibitor Use of levodopa and catechol-O-methyltransferase inhibitors Autoimmunity to intrinsic factor Gastric infection with Helicobacter pylori Ileocystoplasty Atrophic gastritis Increased requirements During pregnancy and lactation Increased excretion Alcoholism 5 6 7 6 9 10 11 12 Box 2 – Diagram illustrating vitamin B12 digestion and absorption (#)15 ,16 Box 3 – Recommended dietary intake (RDI)* and estimated average requirement (EAR) of vitamin B12 per day (#) † 26 Sex and age group RDI EAR Men = 19 years 2.4 µg 2.0 µg Women = 19 years 2.4 µg 2.0 µg Pregnant women 2.6 µg 2.2 µg Lactating women 2.8 µg 2.4 µg
  14. 14. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 6/11 Children 0–6 months 0.4 µg 7–12 months 0.5 µg 1–3 years 0.9 µg 0.7 µg 4–8 years 1.2 µg 1.0 µg 9–13 years 1.8 µg 1.5 µg 14–18 years 2.4 µg 2.0 µg * The RDI is the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all healthy individuals (97%–98%) of a particular sex and life stage. The EAR is a daily nutrient level estimated to meet the requirements of half the healthy individuals of a particular sex and life stage. These values are adequate intakes, which are the average daily nutrient intake levels based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate. ‡ ‡ † ‡ Box 4 – A sample vegetarian meal plan designed to meet requirements for vitamin B12 and other key nutrients for a 19–50-year-old woman, showing vitamin B12 content of the foods* (#) Meal Vitamin B12 content Breakfast Bowl of cereal with fruit, and poached egg on toast 2 wholegrain wheat biscuits 0.0 µg 4 strawberries 0.0 µg 10 g chia seeds 0.0 µg 1/2 cup low-fat fortified soy milk (or dairy milk) 0.5 µg (0.8 µg) 1 slice multigrain toast 0.0 µg 1 poached egg 0.9 µg Snack Nuts and dried fruit 30 g cashews 0.0 µg 6 dried apricot halves 0.0 µg Lunch Chickpea falafel wrap 1 wholemeal pita flatbread 0.0 µg 1 chickpea falafel 0.0 µg 30 g hummus 0.0 µg 1/2 cup tabouli 0.0 µg Salad 0.0 µg †
  15. 15. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 7/11 Provenance: Commissioned by supplement editors; externally peer reviewed. Snack Banana and wheatgerm smoothie 3/4 cup low-fat fortified soy milk (or dairy milk) 0.8 µg (1.1 µg) 2 teaspoons wheatgerm 0.0 µg 1 banana 0.0 µg Dinner Stir-fry greens with tofu and rice 100 g tofu 0.0 µg 2 spears asparagus, 1/3 cup bok choy and 25 g snow peas 0.0 µg 1 cup cooked brown rice 0.0 µg Snack Fortified malted chocolate beverage 1 cup low-fat fortified soy milk (or dairy milk) 1.0 µg (1.5 µg) 10 g malted chocolate powder 0.0 µg Total vitamin B12 3.2 µg (4.3 µg) * Source: FoodWorks 2009 (incorporating Food Standards Australia New Zealand’s AUSNUT [Australian Food and Nutrient Database] 1999), Xyris Software, Brisbane, Qld. Figures are for soy milk (dairy milk). † † † † Box 5 – Vitamin B12 content of lacto-ovo-vegetarian food sources* (#) Vegetarian sources Vitamin B12 per 100 g Sausage, vegetarian style, fortified 2.0 µg Cheese, cheddar, reduced fat (16%) 1.8 µg Egg (chicken), whole, poached 1.7 µg Milk, cow, fluid, regular or reduced fat 0.6 µg Soy beverage, unflavoured, regular fat, fortified 0.9 µg Soy beverage, unflavoured, reduced fat (1.5%), fortified 0.9 µg Soy beverage, unflavoured, low fat, (0.5%), fortified 0.3 µg Yoghurt dessert, regular fat, flavoured 0.2 µg * From Food Standards Australia New Zealand. NUTTAB 2010 online searchable database.43
  16. 16. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 8/11 Correspondence: ( Acknowledgements: We acknowledge the assistance of dietitians Sue Radd and Rebecca Prior in the early development stages of this article. Competing Interests: Kate Marsh previously consulted for Nuts for Life (Horticulture Australia), who are providing a contribution towards the cost of publishing this supplement. Angela Saunders, Michelle Reid and Melinda Ramsay are employed by Sanitarium Health and Wellbeing, sponsor of this supplement. 1. Cameron DG, Townsend SR, English A. Pernicious anaemia II: maintenance treatment with crystalline vitamin B12. Can Med Assoc J 1954; 70: 398-400. <PubMed> ( cmd=Retrieve&db=PubMed&list_uids=13150272&dopt=Abstract) 2. Gilsing AM, Crowe FL, Lloyd-Wright Z, et al. Serum concentrations of vitamin B12 and folate in British male omnivores, vegetarians and vegans: results from a cross-sectional analysis of the EPIC-Oxford cohort study. Eur J Clin Nutr 2010; 64: 933-939. <PubMed> ( 3. Allen RH, Stabler SP, Savage DG, Lindenbaum J. Metabolic abnormalities in cobalamin (vitamin B12) and folate deficiency. FASEB J 1993; 7: 1344-1353. <PubMed> ( cmd=Retrieve&db=PubMed&list_uids=7901104&dopt=Abstract) 4. Mangels R, Messina V, Messina M. The dietitians’ guide to vegetarian diets: issues and applications. 3rd ed. Sudbury, MA: Jones & Bartlett Learning, 2010. 5. Schubert ML. Gastric secretion. Curr Opin Gastroenterol 2007; 23: 595-601. <PubMed> ( 6. Aarts EO, Janssen IM, Berends FJ. The gastric sleeve: losing weight as fast as micronutrients? Obes Surg 2011; 21: 207-211. <PubMed> ( 7. Yakut M, Ustün Y, Kabaçam G, Soykan I. Serum vitamin B12 and folate status in patients with inflammatory bowel diseases. Eur J Intern Med 2010; 21: 320-323. <PubMed> ( cmd=Retrieve&db=PubMed&list_uids=20603044&dopt=Abstract) 8. De Jager J, Kooy A, Lehert P, et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomised placebo controlled trial. BMJ 2010; 340: c2181. <PubMed> ( 9. Tal S, Shavit Y, Stern F, Malnick S. Association between vitamin B12 levels and mortality in hospitalized older adults. J Am Geriatr Soc 2010; 58: 523-526. <PubMed> ( cmd=Retrieve&db=PubMed&list_uids=20158555&dopt=Abstract) 10. Triantafyllou NI, Kararizou E, Angelopoulos E, et al. The influence of levodopa and the COMT inhibitor on serum vitamin B12 and folate levels in Parkinson’s disease patients. Eur Neurol 2007; 58: 96-99. <PubMed> Carol L Zeuschner, BSc, MSc, APD, Manager of Nutrition and Dietetics Bevan D Hokin, BSc, MAppSc, PhD, Director of Pathology Kate A Marsh, AdvAPD, MNutrDiet, PhD, Director and Senior Dietitian Angela V Saunders, BS(Dietetics), MA(Ldshp&Mgmt–HS), APD, Senior Dietitian, Science and Advocacy Michelle A Reid, BND, APD, AN, Senior Dietitian, Nutrition Marketing Melinda R Ramsay, BMedSci, MNutrDiet, APD, Project Coordinator 1 Sydney Adventist Hospital, Sydney, NSW. 2 Northside Nutrition and Dietetics, Sydney, NSW. 3 Corporate Nutrition, Sanitarium Health and Wellbeing, Berkeley Vale, NSW. 4 Sanitarium Health and Wellbeing Services, Sanitarium Health and Wellbeing, Sydney, NSW. 1 1 2 3 3 4
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  19. 19. 8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia 11/11 cmd=Retrieve&db=PubMed&list_uids=19256490&dopt=Abstract) 42. Dagnelie PC, van Staveren WA, van den Berg H. Vitamin B-12 from algae appears not to be bioavailable. Am J Clin Nutr 1991; 53: 695-697. <PubMed> ( 43. Food Standards Australia New Zealand. NUTTAB 2010 online searchable database. database/onlineversion.cfm ( (accessed Nov 2011). 44. Yazaki Y, Chow G, Mattie M. A single-center, double-blinded, randomized controlled study to evaluate the relative efficacy of sublingual and oral vitamin B-complex administration in reducing total serum homocysteine levels. J Altern Complement Med 2006; 12: 881-885. <PubMed> ( cmd=Retrieve&db=PubMed&list_uids=17109579&dopt=Abstract)
  20. 20. Vegetarian Diets During Lactation RD Resources for Consumers: A balanced vegetarian diet supports healthy breastfeeding. Lower levels of environmental toxins are found in milk from women who follow a vegetarian diet. Breastfed children of well-nourished vegetarian mothers grow and develop normally. Benefits of Breastfeeding Breast milk is best. It provides all the nutrients a growing infant needs in the most digestible form. Breastfeeding is free, convenient and supports mother-child bonding. The most benefits are gained when children are breastfed for at least the first 6 months after birth. Children build stronger immune systems, suffer from less allergies, and have reduced risk of obesity later in life. Mothers reduce their risk of some cancers, and type 2 diabetes. Calorie Needs and Weight Loss The body uses extra calories when producing breast milk. Increased calorie needs are based on the amount of milk produced. On average, women use 330 more calories each day for the first 6 months of breastfeeding. During the second 6 months, they use an additional 400 calories. While this will aid in healthy weight loss after pregnancy, extra calorie intake will also be needed. To meet higher calorie needs, consume plenty of whole-grains, fruits, vegetables, legumes, nuts, and seeds. Visit breastfeeding_weight_loss.html for more information. Tandem Nursing When a woman nurses two children of different ages it is called“tandem nursing.”Producing milk for two children requires more calories and nutrients than needed to feed one. High calorie and high nutrient foods in snacks and meals provide good sources of additional calorie intake. Remaining hydrated, by drinking extra water, is also highly recommended. High calorie, High nutrient foods • Avocado • Nuts & nut butters • Seeds & seed butters • Dried fruits • Full-fat soy products • Bean spreads • Fruit juices 300-Calorie Snack Ideas • Whole-grain toast with 1½ tbsp. almond butter topped with sliced banana and strawberries • ½ cup hummus with 1 cup of raw carrots and bell peppers • Fruit smoothie with 1 cup frozen mango, ½ cup frozen pineapple, 1 cup soymilk • ¼ cup guacamole with 1/3 cup baked tortilla chips • ¼ cup of trail mix Fluid Needs Fluid needs increase while breastfeeding, therefore staying hydrated is key. Drink water throughout the day and while nursing. Low-fat or non-fat milk, 100% fruit juices, and soups are also good sources of fluid. tip
  21. 21. Important Nutrients Protein (.59 g/lb.) Example: A woman who weighs 150 lbs. would need approximately 89 g of protein per day (150 lbs x .59 g/lb = 88.5 g) • Dried beans • Tofu & Tempeh • Nuts & nut butters • Eggs • Soymilk • Whole-grains • Dairy products Omega-3 Fatty Acid-DHA • Eggs from chickens fed a DHA-rich diet • Foods fortified with microalgae-derived DHA Vegetarian & Vegan-friendly DHA supplements may be used. Vitamin B12 (2.6 mcg/day) • Fortified cereals • Fortified soymilk • Vitamin B12-fortified nutritional yeast • Milk and yogurt • Eggs Calcium (1,000 mg/day) • Fortified soymilk or rice milk • Dairy products • Calcium-set tofu • Some dark green leafy vegetables (e.g. broccoli, kale, collard greens, bok choy) • Soybeans • Almonds • Figs • Fortified orange juice Vitamin D (200 IU/day) • Cow’s milk • Fortified cereals • Vitamin D-fortified soymilk • Skin exposure to sunlight Breastfed infants should be given a 400 IU vitamin D supplement daily. tip tip RD Resources are a project of the Vegetarian Nutrition Dietetic Practice Group. More topics available at Professional resources also available for members at © 2010 by VN DPG. Written by: Christine Creighton, MS, RD Expires April 2015. RD Resources for Consumers: Vegetarian Diets During Lactation Choose high calcium foods from each of the food groups (e.g. calcium-fortified breakfast cereals, bok choy, broccoli, collards, Chinese cabbage, kale, mustard greens, okra, calcium-fortified orange juice, dairy products, calcium-fortified soy milk, tempeh, calcium-set tofu, almonds). tip Resources MyPyramid for Pregnancy & Breastfeeding, index.html Raising Vegetarian Children by Joanne Stepaniak and Vesanto Melina Simply Vegan, 4th ed. by Debra Wasserman and Reed Mangels The Vegetarian Mother’s Cookbook by Cathe Olson Meal Planning Guidelines for Breastfeeding Vegetarians Food Group Grains Vegetables Fruits Legumes, nuts, seeds, milks Fats # of Svgs. 6 4 2 7 2 Serving Size 1 slice bread; ½ cup cooked cereal or pasta; ¾ - 1 cup ready-to-eat cereal ½ cup cooked vegetables; 1 cup raw vegetables; ¾ cup vegetable juice ½ cup canned fruit; 1 medium fruit; ¾ cup fruit juice ½ cup cooked beans, tofu, tempeh, textured vegetable protein (TVP); 3 ounces meat analog; 2 tbsp. nuts, seeds, nut or seed butter; 1 cup fortified soy or rice milk; 1 cup cow’s milk; 1 cup yogurt 1 tsp. oil or margarine Comments Choose whole or enriched grains Choose these calcium-rich foods often: dark green leafy vegetables (kale, collards, and mustard greens), broccoli, bok choy, Chinese cabbage, okra Choose these calcium-rich foods often: calcium- fortified juice, figs Choose these calcium-rich foods often: calcium- fortified soymilk, cow’s milk, yogurt, calcium-set tofu, almond butter, tahini, tempeh, almonds, cheese, soybeans The MyPyramid for Pregnancy and Breastfeeding Web site ( provides meal plans that can be adapt for breastfeeding women who follow lacto-ovo and lacto vegetarian diets. MyPyramid for Pregnancy and Breastfeeding offers limited information for women following vegan diets. The following meal plan can be used for pregnant vegans. These guidelines are the suggested minimum number of servings for breastfeeding women. Some women may need additional servings and/or added fats to maintain desirable body weight.
  22. 22. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Healthy eating for vegan pregnant and breastfeeding mothers Healthy eating is important at all stages of life, especially during pregnancy. Your choices of what to eat and drink at this time can affect your health and the health of your baby for many years to come. A well planned vegan diet is able to meet nutrition requirements for pregnancy and breastfeeding. There is only a small increase in the amount of food you need to eat while you are pregnant. However, you do need more of certain nutrients, so it is very important that you make good choices for a nutritious diet. This is important so you and your baby get all you need for healthy growth and a healthy pregnancy. Healthy eating is important when you are breastfeeding. Your body has a greater need for most nutrients. Some of the extra energy required for breastfeeding comes from body fat stored during pregnancy. To meet your extra nutrient needs, it is important to eat a variety of nutritious foods. Your daily food group requirements during pregnancy and breastfeeding are outlined in the table on the next page. Use the numbers in the middle column to guide how many serves to eat from each food group per day. One serve is equal to each of the foods in the column on the right. For example, one serve of fruit is equal to 2 small plums. One serve of grain (cereal) foods is equal to ½ cup of cooked pasta.
  23. 23. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Food Group Number of Serves 1 serve Vegetables and legumes/ beans Pregnant 5 Breast Feeding 7½ ½ cup cooked green or orange vegetables (e.g. broccoli, carrot, pumpkin or spinach) ½ cup cooked, dried or canned beans, chickpeas or lentils (no added salt) 1 cup raw leafy green vegetables ½ medium potato, or other starchy vegetable (sweet potato, taro, or cassava) ½ cup sweet corn 75 g other vegetables e.g. 1 small- medium tomato Fruit Pregnant 2 Breast Feeding 2 1 piece medium sized fruit (e.g. apple, banana, orange, pear) 2 pieces smaller fruit (e.g. apricot, kiwi fruit, plums) 1 cup diced, cooked or canned fruit ½ cup 100% juice 30 g dried fruit (e.g. 1½ tbsp sultanas, 4 dried apricot halves) Grain (cereal) foods Pregnant 8½ Breast Feeding 9 1 slice of bread ½ medium bread roll or flat bread ½ cup cooked rice, pasta, noodles, polenta, quinoa, barley, porridge, buckwheat, semolina, cornmeal ⅔ cup breakfast cereal flakes ¼ cup muesli 3 crisp breads 1 crumpet or 1 small English muffin or scone Nuts, seeds and legumes Pregnant 3½ Breast Feeding 2½ 1 cup (170 g) cooked dried beans, lentils, chickpeas, split peas, canned beans 170 g tofu 1/3 cup (30 g) unsalted nuts, seeds or paste, no added salt Dairy alternatives Pregnant 2½ Breast Feeding 2½ 1 cup (250 ml) calcium fortified soy milk 200 g (3/4 cup) calcium fortified soy yoghurt 2 (40 g) slices of soy cheese Additional serves for taller or more active women 0–2½ 3–4 sweet biscuits 30 g potato crisps 2 scoops soy ice-cream 1 Tbsp (20 g) dairy-free butter, margarine, oil
  24. 24. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Protein Pregnant or breastfeeding women should aim to include protein sources at each meal such as nuts, seeds, soy products and dried beans and peas. Folate or Folic acid during pregnancy Folate (or folic acid) is needed for the growth and development of your baby. It is especially important in the month before you fall pregnant and the first trimester (three months) of pregnancy. A good intake of folate reduces the risks of your baby being born with some abnormalities such as spina bifida (a disorder where the baby’s spinal cord does not form properly). Dietary sources high in folate include green vegetables such as broccoli, spinach and salad greens, some fruits and fortified cereals. All women planning a pregnancy and in the early stages of pregnancy should eat a variety of folate-containing foods (e.g. green leafy vegetables such as spinach, broccoli, bok choy, and foods fortified with folic acid— fruit juice, bread, breakfast cereal). You should also take a folic acid supplement of 400 micrograms per day at least one month before and three months after you become pregnant. Iron during pregnancy Iron is needed to form the red blood cells for you and your baby. It helps carry oxygen in your blood and is needed for your baby to grow. During pregnancy you need a lot more iron than when you are not pregnant so for women who follow a vegan diet an iron supplement is highly recommended. Good sources of additional dietary iron are legumes, (e.g. beans, peas, lentils) dark green vegetables, dried fruits, nuts, fortified soy milks, breakfast cereals and wholemeal breads. Vitamin C will help its absorption, so combine it with citrus fruit, berries, juice or tomato. Talk to your dietitian or midwife to make sure you are getting enough iron from your diet. What you eat or drink can stop your body using iron from your diet. You should limit your intake of these. They include: • drinking tea or coffee with meals • eating more than 2 tablespoons of unprocessed bran. You can help your body get iron from the food you eat or drink by: • including vitamin C with meals (e.g. citrus foods, tomato, capsicum) • using antacids sparingly.
  25. 25. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Iodine Adequate iodine in pregnancy is essential for your baby’s growth and brain development. Iodine is needed in higher amounts during pregnancy. It is now recommended that all pregnant women should take a supplement containing 150 micrograms of iodine. You still need to consume good food sources of iodine in addition to this supplement. These food sources include: - iodised salt (look for green label) - bread with added iodine - fortified margarine. Fluid When you are breastfeeding you need more to drink to replace the fluid used in breast milk (~700 ml/day). It is a good idea to have a drink, such as a glass of water or fat reduced milk (within your nutrition needs) every time your baby feeds. You will also need to drink more fluid at other times during the day too. Multivitamin supplements A folate supplement is important during the first trimester of pregnancy. You may also need to take an iron supplement if your iron levels are low. However, a multivitamin during pregnancy is not necessary unless you do not have a balanced diet – compare what you are eating with the table on the first page of this sheet. If you choose to take a vitamin or mineral supplement during pregnancy, choose one that is specifically designed for pregnancy. Always check with your doctor before taking any supplements as an excessive intake of these can be harmful and reduce the absorption of other nutrients. Calcium Calcium fortified soy products are important to meet calcium requirements whilst pregnant. Also include tofu, almonds, sesame seeds and tahini. Vitamin B12 Significant amounts of B12 are usually found in animal products, so your intake will be limited. A good amount can be consumed by having at least two serves of soy milk fortified with B12 daily. Food fermented by micro-organisms (soy sauce, miso, tempeh), manure-grown mushrooms, spirulina and yeast may contain small amounts of vitamin B12, but this is not sufficient to meet your requirements for vitamin B12. Discuss your vitamin B12 levels and requirements with your doctor or midwife.
  26. 26. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Zinc Good sources for vegans include beans and lentils, yeast, nuts, seeds and wholegrain cereals. Pumpkin seeds provide one of the most concentrated vegan food sources of zinc. Weight Gain The amount of weight to gain during pregnancy will depend on what your weight was before you became pregnant. Your midwife or dietitian will be able to calculate your body mass index (BMI) (a measure of your weight for height) to help you work this out. If your pre-pregnancy BMI was… You should gain… Less than 18.5 kg/m² 18.5 to 24.9 kg/m² 25 to 29.9 kg/m² Above 30 kg/m² 12½ to 18kg 11½ to 16kg 7 to 11½ kg 5 to 9kg As well as having an overall weight gain goal for your pregnancy, there is a trimester by trimester guideline to follow, as well. How much should I gain in my first trimester? All women can expect to gain one or two kilograms in the first three months of pregnancy. How much should I gain in my second and third trimesters? This depends on your pre-pregnancy BMI. Refer to the table below to see your goal. If your pre-pregnancy BMI was… You should gain… Less than 18.5 kg/m² ½ kg/week 18.5 to 24.9 kg/m² 400g/week Above 25kg/m² Less than 300g/ week It is important to keep your weight gain in this range for both your health and the health of your baby. Not gaining enough weight means your baby may miss out on some important nutrients. This can cause problems later in life. Insufficient weight gain is also linked with preterm birth. Gaining too much weight during pregnancy can also cause problems such as high blood pressure, gestational diabetes, complications in delivery, and longer hospital stays for you or your baby. These problems can be harmful to both you and your baby.
  27. 27. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Food safety during pregnancy Hormonal changes during pregnancy may make your immune system weaker. This can make it harder to fight infections. Foods are sometimes a source of infections so protecting yourself from food poisoning is important. Listeria Listeria is a bacteria found in some foods, which can cause an infection called listeriosis. If passed on to your unborn baby it can cause premature birth, miscarriage or damage. The risk is the same through your whole pregnancy. Always keep your food ‘safe’ by: • Choose freshly cooked and freshly prepared food. • Thawing food in the fridge or defrosting food in the microwave. • Cooling left over food in the fridge rather than the bench. • Wash your hands, chopping boards and knives after handling raw foods. • Make sure hot foods are hot (above 60 degrees Celsius) and cold foods are cold (below 5 degrees Celsius), both at home and when eating out. • Make sure all food is fresh, used within the used-by date. • Eat left overs within 24 hours and reheat foods to steaming hot. • Heat leftovers to above 74 degrees for over 2 minutes. • Never re-freeze food once it has been thawed. • Ready-to-eat salads (from salad bars, buffets, supermarkets etc.) are foods that may contain Listeria and should be avoided. Some other bacteria and parasites can be harmful to your unborn baby. In addition to the precautions above: • Wear gloves when gardening and wash hands afterwards. • Avoid contact with cats and use gloves when handling cat litter (cats can be a source of Toxoplasmosis– a serious infection that can cause defects or death in your baby).
  28. 28. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Special Considerations during Pregnancy Caffeine During pregnancy caffeine takes longer to break down in your body. Generally 2–3 cups of coffee or up to 4 cups of tea a day are okay, but decaffeinated drinks are a better alternative. Try to limit your intake of caffeine containing drinks and foods. Alcohol Alcohol crosses the placenta and can lead to physical, growth and mental problems in babies. There is no known safe level of alcohol consumption during pregnancy. The safest option is not to drink during your pregnancy. Nausea and vomiting Many women suffer from sickness, usually in early pregnancy. Morning sickness is usually caused by the hormonal changes of pregnancy, and can affect you at any time of the day. By the end of the 4th month of pregnancy, symptoms usually disappear or become much milder. Some tips to help morning sickness: • Eat small amounts every two hours — an empty stomach can cause nausea. • Avoid smells and foods that make your sickness worse. • Eat more nutritious carbohydrate foods: try dry toasts or crackers, breakfast cereals and fruit. • Eat less fatty and sugary foods. Heartburn Heartburn, or reflux, is a burning feeling in the middle of the chest that can also affect the back of the throat. It is caused when acid moves from the stomach, back up the oesophagus. This happens because hormonal changes during pregnancy relax stomach muscles, and also because as the baby grows, more pressure is put on your stomach. Some tips to reduce heartburn: • eat small regular meals more often • avoid fatty, fried or spicy foods • avoid tea, coffee, cola drinks, chocolate drinks and alcohol • sit up straight while eating • do not bend after meals or wear tight clothes • sleep propped up on a couple of pillows.
  29. 29. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Constipation Constipation is common during pregnancy. Hormone changes may relax the muscles in your bowel, which together with pressure from the growing baby can slow down your bowel movements. It is important to have enough fibre, fluid and exercise to avoid constipation. Good sources of dietary fibre include; vegetables, fruit, wholegrain and high fibre breakfast cereals, wholegrain bread, nuts, seeds and legumes. Water is the best drink. Now that you are up to date on healthy eating for yourself you need to start thinking about nutrition for you baby when he or she arrives. Mothers & Babies are designed for Breastfeeding Breastfeeding is the natural, normal way to feed your baby. Breastmilk is a complex food. It changes to meet the particular needs of each child from the very premature baby to the older toddler. Food for Health Breastfeeding has an amazingly positive effect on the health of both mothers and babies. For this reason, the World Health Organisation (WHO) and the Australian Department of Health recommend that all babies are breastfed exclusively (ie. no other food or drinks) for around the first 6 months and then continue to receive breastmilk (along with complementary food and drink) into the child’s 2nd year and beyond. Research shows that the longer the breastfeeding relationship continues, the greater the positive health effects. Breastmilk provides: Protection for baby from infections such as ear, stomach, chest and urinary tract; diabetes, obesity, heart disease, some cancers, some allergies and asthma. Protection for mother from breast and ovarian cancers, osteoporosis and other illnesses. Healthier communities & environment.
  30. 30. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Preparing to Succeed Research shows that nearly all of women are able to meet the breastmilk needs of their babies. Ask the midwife to put your baby skin to skin on your chest as soon as possible after birth. Take the midwife up on her offer to help your baby lead attachment to your breast. Talk to your family, friends and workplace about your decision to breastfeed so they are ready to support you once your baby has arrived. Avoiding certain foods during breastfeeding Mothers may be told to avoid certain foods when breastfeeding. However, there is no evidence to support the claims that either colic or allergic reactions in infants are caused by the mother’s diet. Allergic reactions are rare in breast fed babies. If this does occur, the mother’s diet should only be modified in consultation with her doctor and dietitian Trying to lose weight while breastfeeding Breast feeding helps you shape up. The greatest amount of weight loss generally occurs in the first 3 months after birth and then continues at a slow and steady rate until 6 months after birth. Breastfeeding your baby should help you return to your pre-pregnancy weight, as some of the fat stores you laid down during pregnancy are used as fuel to make breast milk. Continue breastfeeding for at least 12 months, into the second year of life and for as long as you and your baby & are happy to continue. When you are trying to lose your pregnancy weight, it is important you do not follow a very restrictive diet plan. You need to make nutritious breast milk and stay healthy yourself. Try these helpful hints: • Follow the meal plan in this handout or similar. • Do not skip meals. • Limit foods high in fat and sugar such as lollies, chocolate, soft drinks, cakes, sweet biscuits, chips and fatty take-away food. • Use healthy cooking methods such as steaming, boiling, microwaving, grilling and stir frying. • Do some gentle exercise such as taking your baby for a walk. If available attend physiotherapy postnatal classes. • Plan your healthy meals and snacks ahead of time.
  31. 31. This is a consensus document by Queensland Dietitians. Last reviewed: June 2013 Disclaimer: Review: June 2015 Are you losing weight too quickly? If you are losing too much weight when you are breastfeeding it is important you do not stop breastfeeding. Instead, find ways to eat more nutritious foods. Try these suggestions: • Don’t skip meals. • Have three main meals and three between-meal snacks. • Keep easy to prepare nutritious snacks on hand (e.g. crisp-breads and cheese, fresh fruit, soy yoghurt, nuts, seeds, dried fruit, canned beans, fruit smoothies, breakfast cereals and soy milk). • Prepare a packed lunch or variety of snacks to have in a container beside you when breastfeeding. • Prepare and freeze meals in advance when possible (or ask your friends/family to help). • Plan your healthy meals & snacks ahead of time. For further breastfeeding information go to Things I can do to improve my diet for a healthy pregnancy and/or while breastfeeding: 1. 2. 3. 4. For further information contact your Dietitian or Nutritionist:_____________________ References: 1. Eat for Health Australian Dietary Guidelines. 2013. Commonwealth of Australia. 2. Foods Standards Australia and New Zealand, Listeria and food fact sheet, 2005. 3. Food Standards Australia and New Zealand, Mercury in Fish fact sheet, 2004. 4. Institute of Medicine (2009). Weight Gain During Pregnancy: Re-examining the Guidelines, National Academies Press. 5. National Health and Medical Research Council (2010), Public Statement, Iodine Supplementation for pregnant and breastfeeding women. 6. National Health and Medical Research Council (2006). Nutrient Reference Values for Australia and New Zealand Executive Summary. Dept. Health and Ageing. Canberra, Commonwealth of Australia. 7. Queensland Health. Optimal infant nutrition: evidence-based guidelines 2003-2008.Queensland Health Brisbane 2003. 8. World Health Organisation. Global Strategy for Infant and Young Child Feeding. World Health Organisation, 2003. 9. World Health Organisation. Infant Feeding: The Physiological Basis. 1996. James Akre (ed), WHO, Geneva. 10. Zimmermann M, Delange F. Iodine supplementation of pregnant women in Europe: a review and recommendations. Eur JClin Nutr 2004;58:979-984.
  32. 32. The Vegetarian Breastfeeding Mother Mel Wolk St. Peters, Missouri, USA From: LEAVEN, Vol. 33 No. 3, June-July 1997, p. 69 We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time. Ed. Note: From time to time, Leaders receive questions about diet from vegetarian mothers. The BREASTFEEDING ANSWER BOOK is a helpful resource. Vegetarian diets include several variations: Vegan - no flesh foods (red meat, poultry, fish), milk products or eggs. Ovo-lacto vegetarian - no flesh foods but milk products and eggs are allowed. Ovo vegetarian - no flesh foods or milk prod- ucts, but eggs are allowed. Lacto vegetarian - no flesh foods or eggs, but milk products are al- lowed. Vegetarian diets that contain no animal protein may require vitamin B12 supplementation to avoid a deficiency in mother or baby. In babies, symptoms may include loss of appetite, regression in motor development, lethargy, muscle atrophy, vomiting or blood abnormalities. Mothers of babies with symptoms may or may not exhibit symptoms themselves. Mothers on vegan diets who do not consume animal products do have alternatives. They can ask their health care provider about using a vitamin B12 supplement or adding fermented soybean foods and yeast (both contain some vitamin B12) to their diets. Another option would be to ask their health care provider about the need to supplement the baby with vitamin B12. Even though one study showed vegetarian mothers tend to consume less calcium than other mothers, levels of calcium in human milk were not affected. This is believed to be caused by the fact that vegetarians consume less protein and therefore need less calcium. Vegetarian mothers who do not consume milk or other dairy products will want to take special care to eat foods rich in calcium. One cup (227 grams) of cooked bok choy, a type of cabbage, will provide 86% of the calcium in one cup (240 ml.) Of milk. One half cup (113 grams) of ground sesame seeds contains twice as much calcium as one cup (240 ml.) of milk. Other sources of calcium include blackstrap molasses, tofu, collard greens, spinach, broccoli, turnip greens, kale, almonds and Brazil nuts. While vegetarian mothers in the same study had low vitamin D levels, supplements are not usu- ally recommended because most mothers and babies receive adequate vitamin D through expo- sure to the sun. Research suggests that women with dark skin, or those who wear traditional, en- veloping clothing that allows little exposure of skin to sunlight may need to consider a vitamin D supplement for themselves or their babies. The milk of vegetarian mothers is lower in environmental contaminants than the milk of non- vegetarian mothers. Environmental contaminants are stored mainly in fat. Vegetarian diets tend to be lower in fat than those containing animal products, so there is less transfer into human milk. Leaders can assure vegetarian mothers that their diet should not present a problem when breast- feeding their babies.
  33. 33. References Dagnelie P. et al. Nutrients and contaminants in human milk from mothers on macrobiotic and ominivorous diets. European Journal of Clinical Nutrition 1992; 46:355-66. Fuhrman, J. Osteoperosis: how to get it and how to avoid it. Health Science Jan/Feb 1992; 8-11. Kuhn, T. et al. Maternal vegan diet causing a serious infantile neurological disorder due to vitamin B12 defi- ciency. European Journal of Clinical Nutrition 1991; 150:205-08. Lawrence, R. Breastfeeding: A Guide for the Medical Profession, 4th ed. St. Louis: Mosby; 1994, pp. 104-15, 290-91, 300-02, 657. Specker, B. Nutritional concerns of lactating women consuming vegetarian diets. American Journal of Clinical Nutrition 1994; 54(Suppl): 1182S-86S.
  34. 34. Infant Formulas Unfortunately there is currently no infant formula available which is suitable for vegans. There are soya formulas on the market, such as SMA’s Wysoy and Cow and Gate’s Infasoy, but these are not 100% vegan as they are fortified with vitamin D3, which is made from lanolin (a grease produced by sheep’s skin and extracted from their wool). The vegan-suitable formula which was previously available, Heinz Nurture Soya (formerly Farley’s Soya), is no longer manufactured as Heinz no longer produce any infant formulas. Formula Milk & Soya Milk Some concern has been expressed regarding the relationship between the glucose content of soya formula and tooth decay in children. The energy content is based on glucose syrup rather than lactose (milk sugar) and it has been thought to have a greater potential to contribute to dental caries than cow's milk formulas. No studies have shown that soya infant formula is any more harmful to teeth than dairy infant for- mula. Feeds from a bottle, feeding at bedtime, prolonged sucking, may be the most important factors in predicting caries development (Moynham et al 1996). If normal weaning practices are adopted, infant formulas should not cause harm to teeth. When bottle feeding, do not allow prolonged or frequent contact of milk feeds with your baby's teeth since this increases the risk of tooth decay. As soon as the first tooth erupts (usually appears any time between 6 and 12 months although they may come through sooner or later than this) brush twice daily. Make sure your baby's teeth are cleaned after the last feed at night and try to wean your baby off the bottle by the age of one. Glucose syrup has several properties that make its use in soya formulas appropriate. It is easily absorbed and utilised by infants even when the gut mucosa is damaged. The use of glucose syrup as the carbohydrate in a soya formula ensures a similar osmolal- ity to breast milk. Glucose syrup is easily mixed with water, which is essential for home preparation, and the naturally bitter taste of soya protein is effectively masked by glu- cose syrup without causing undue sweetness. Formula should be fed from a feeding bottle. However, between the ages of six and 12 months a beaker or cup should be increasingly used. The use of a bottle should not be prolonged and teeth should be cleaned after feeds. Regarding tooth decay, evidence indicates that the quantity of sugar eaten is less important than the time taken to con- sume them and the interval before further sugar is eaten. If sugary foods or drinks are consumed, it is better to ensure they are finished relatively quickly rather than eaten over several hours as the mouth pH can be restored within 30 minutes. It is important that ordinary soya milk should not substituted for soya infant formula as it does not contain the proper ratio of protein, fat, carbohydrate, nor the vitamins and minerals required to be used as a sole food. Soya milk should also not be substituted to babies under 6 months of age because it has levels of protein which are too high and excessive protein intake is thought to be medically undesirable at this stage.
  35. 35. Breastfeeding and Fenugreek Betty H. Greenman: Posted on Wednesday, July 10, 2013 3:06 PM Many moms are interested in increasing their milk supply. The number one choice is Fenugreek. Fenugreek is an herb that many moms say that it increases their milk supply in only a few days. Fenugreek comes in capsule, powder seed or tea form. Some moms even get creative and bake cookis with Fenugreek in them. You should discuss using Fenugreek with your doctor before you get started taking this. If you have a history of diabetes, hypoglycemia, asthma, abnormal menstrual cycles, peanut or chickpea allergies, migraines, blood pressure problems, or heart disease, Fenugreek is not for you. When the mother takes large amounts of Fenugreek, sometimes she smells like maple syrup. Also, the baby can smell like maple syrup. Sometimes this can be misleading because there is a serious metabolic disorder that babies can be misdiagnosed as having. Also, Fenugreek is an herb related to the peanut family. Therefore, people who have allergies to peanuts, need to stay away. Some babies may have upset stomachs or even diarrhea when mom takes Fenugreek. Some women experience upset stomachs as well. Although herbs are natural, they are not always safe to use. Therefore, breastfeeding moms should be cau- tious when taking Fenugreek. The Food and Drug Administration (FDA) is mandated to control medications and infant formulas in the United States. However, they do not control herbs. Therefore, there are no requirements to list ingredients on the label. Furthermore, some herbs interfere with other medications so speak to your doctor before taking Fenugreek. In conclusion, always discuss any supplemental herbs you are taking while breastfeeding with your doctor. Many women today take Fenugreek in a pill form. Most vitamins and many supermarkets carry this product.If you or your baby are experiencing any side effects, stop taking Fenugreek immediately. Resources:
  37. 37. The World Health Organization was established in 1948 as a specialized agency of the United Nations serving as the directing and coordinating authority for international health matters and public health. One of WHO’s constitutional functions is to provide objective and reliable information and advice in the field of human health, a responsibility that it fulfils in part through its extensive programme of publications. The Organization seeks through its publications to support national health strategies and address the most pressing public health concerns of populations around the world. To respond to the needs of Member States at all levels of development, WHO publishes practical manuals, handbooks and training material for specific categories of health workers; internationally applicable guidelines and standards; reviews and analyses of health policies, programmes and research; and state-of-the-art consensus reports that offer technical advice and recommendations for decision-makers. These books are closely tied to the Organization’s priority activities, encompassing disease prevention and control, the development of equitable health systems based on primary health care, and health promotion for individuals and communities. Progress towards better health for all also demands the global dissemination and exchange of information that draws on the knowledge and experience of all WHO’s Member countries and the collaboration of world leaders in public health and the biomedical sciences. To ensure the widest possible availability of authoritative information and guidance on health matters, WHO secures the broad international distribution of its publications and encourages their translation and adaptation. By helping to promote and protect health and prevent and control disease throughout the world, WHO’s books contribute to achieving the Organization’s principal objective — the attainment by all people of the highest possible level of health.
  38. 38. GENEVA WORLD HEALTH ORGANIZATION 2002 NUTRIENT ADEQUACY OF EXCLUSIVE BREASTFEEDING FOR THE TERM INFANT DURING THE FIRST SIX MONTHS OF LIFE NANCY F. BUTTE, PHD USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA MARDIA G. LOPEZ-ALARCON, MD, PHD Nutrition Investigation Unit, Pediatric Hospital, CMN, Mexico City, Mexico CUTBERTO GARZA, MD, PHD Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
  39. 39. WHO Library Cataloguing-in-Publication Data Butte, Nancy F. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life / Nancy F. Butte, Mardia G. Lopez-Alarcon, Cutberto Garza. 1.Breastfeeding 2.Milk, Human – chemistry 3.Nutritive value 4.Nutritional requirements 5.Infant I.Lopez-Alarcon, Mardia G. II.Garza, Cutberto III.Expert Consultation on the Optimal Duration of Exclusive Breastfeeding (2001 : Geneva, Switzerland) IV.Title. ISBN 92 4 156211 0 (NLM Classification: WS 125) © World Health Organization 2002 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: Requests for permission to reproduce or translate WHO publications – whether for sale or for non- commercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The named authors alone are responsible for the views expressed in this publication. Designed by minimum graphics Printed in France
  40. 40. Contents iii R E F E R E N C E S Abbreviations & acronyms v Foreword vii Executive summary 1 1. Conceptual framework 3 1.1 Introduction 3 1.2 Using ad libitum intakes to assess adequate nutrient levels 3 1.3 Factorial approaches 4 1.4 Balance methods 5 1.5 Other issues 6 1.5.1 Morbidity patterns 6 1.5.2 Non-continuous growth 6 1.5.3 Estimating the proportion of a group at risk for specific nutrient deficiencies 6 1.5.4 Summary 7 2. Human-milk intake during exclusive breastfeeding in the first year of life 8 2.1 Human-milk intakes 8 2.2 Nutrient intakes of exclusively breastfed infants 8 2.3 Duration of exclusive breastfeeding 8 2.4 Summary 14 3. Energy and specific nutrients 15 3.1 Energy 15 3.1.1 Energy content of human milk 15 3.1.2 Estimates of energy requirements 15 3.1.3 Summary 15 3.2 Proteins 16 3.2.1 Dietary proteins 16 3.2.2 Protein composition of human milk 16 3.2.3 Total nitrogen content of human milk 17 3.2.4 Approaches used to estimate protein requirements 17 3.2.5 Protein intake and growth 20 3.2.6 Plasma amino acids 21 3.2.7 Immune function 21 3.2.8 Infant behaviour 22 3.2.9 Summary 22
  41. 41. 3.3 Vitamin A 22 3.3.1 Introduction 22 3.3.2 Vitamin A in human milk 22 3.3.3 Estimates of vitamin A requirements 23 3.3.4 Plasma retinol 23 3.3.5 Functional end-points 24 3.3.6 Summary 26 3.4 Vitamin D 26 3.4.1 Introduction 26 3.4.2 Factors influencing the vitamin D content of human milk 26 3.4.3 Estimates of vitamin D requirements 27 3.4.4 Vitamin D status and rickets 29 3.4.5 Vitamin D and growth in young infants 29 3.4.6 Vitamin D and growth in older infants 30 3.4.7 Summary 30 3.5 Vitamin B6 30 3.5.1 Introduction 30 3.5.2 Vitamin B6 content in human milk 30 3.5.3 Approaches used to estimate vitamin B6 requirements 31 3.5.4 Estimates of requirements 31 3.5.5 Vitamin B6 status of breastfed infants and lactating women 31 3.5.6 Growth of breastfed infants in relation to vitamin B6 status 32 3.5.7 Summary 32 3.6 Calcium 32 3.6.1 Human milk composition 32 3.6.2 Estimates of calcium requirements 32 3.6.3 Summary 33 3.7 Iron 34 3.7.1 Human milk composition 34 3.7.2 Estimates of iron requirements 34 3.7.3 Summary 35 3.8 Zinc 35 3.8.1 Human milk composition 35 3.8.2 Estimates of zinc requirements 35 3.8.3 Summary 37 References 38 N U T R I E N T A D E Q U A C Y O F E X C L U S I V E B R E A S T F E E D I N G F O R T H E T E R M I N F A N T D U R I N G T H E F I R S T S I X M O N T H S O F L I F E iv
  42. 42. v R E F E R E N C E S Abbreviations & acronyms AI Adequate intake BMD Bone mineral density BMC Bone mineral content CDC Centers for Disease Control and Prevention (USA) DPT Triple vaccine against diphtheria, pertussis and tetanus DXA Dual-energy X-ray absorptiometry EAR Estimated average requirement EAST Erythrocyte aspartate transaminase EPLP Erythrocyte pyridoxal phosphate ESPGAN European Society of Paediatric Gastroenterology FAO Food and Agriculture Organization of the United Nations IDECG International Dietary Energy Consultative Group IU International units NCHS National Center for Health Statistics (USA) NPN Non-protein nitrogen PLP Pyridoxal phosphate PMP Pyridoxamine phosphate PNP Pyridoxine phosphate PTH Parathyroid hormone RE Retinol equivalents SD Standard deviation SDS Standard deviation score UNICEF United Nations Children’s Fund UNU United Nations University WHO World Health Organization
  43. 43. Foreword vii R E F E R E N C E S This review, which was prepared as part of the back- ground documentation for a WHO expert consultation,1 evaluates the nutrient adequacy of exclusive breast- feeding for term infants during the first 6 months of life. Nutrient intakes provided by human milk are compared with infant nutrient requirements. To avoid circular arguments, biochemical and physiological methods, independent of human milk, are used to define these requirements. The review focuses on human-milk nutrients, which may become growth limiting, and on nutrients for which there is a high prevalence of maternal dietary deficiency in some parts of the world; it assesses the adequacy of energy, protein, calcium, iron, zinc, and vitamins A, B6, and D. This task is confounded by the fact that the physiological needs for vitamins A and D, iron, zinc – and possibly other nutrients – are met by the combined availability of nutrients in human milk and endogenous nutrient stores. In evaluating the nutrient adequacy of exclusive breast- feeding, infant nutrient requirements are assessed in terms of relevant functional outcomes. Nutrient adequacy is most commonly evaluated in terms of growth, but other functional outcomes, e.g. immune response and neurodevelopment, are also considered to the extent that available data permit. This review is limited to the nutrient needs of infants. It does not evaluate functional outcomes that depend on other bioactive factors in human milk, or behaviours and practices that are inseparable from breastfeeding, nor does it consider consequences for mothers. In determining the optimal duration of exclusive breast- feeding in specific contexts, it is important that func- tional outcomes, e.g. infant morbidity and mortality, also are taken into consideration. The authors would like to thank the World Health Organization for the opportunity to participate in the expert consultation;1 and Nancy Krebs, Kim Michaelson, Sean Lynch, Donald McCormick, Paul Pencharz, Mary Frances Picciano, Ann Prentice, Bonny Specker and Barbara Underwood for reviewing the draft manuscript. They also express special appreciation for the financial support provided by the United Nations University. 1 Expert consultation on the optimal duration of exclusive breastfeeding, Geneva, World Health Organization, 28–30 March 2001.
  44. 44. 1 Executive summary The dual dependency on exogenous dietary sources and endogenous stores to meet requirements needs to be borne in mind particularly when assessing the adequacy of iron and zinc in human milk. Human milk, which is a poor source of iron and zinc, cannot be altered by maternal supplementation with these two nutrients. It is clear that the estimated iron requirements of infants cannot be met by human milk alone at any stage of infancy. The iron endowment at birth meets the iron needs of the breastfed infant in the first half of infancy, i.e. 0 to 6 months. If an exogenous source of iron is not provided, exclusively breastfed infants are at risk of becoming iron deficient during the second half of infancy. Net zinc absorption from human milk falls short of zinc needs, which appear to be subsidized by prenatal stores. In the absence of studies specifically designed to evaluate the time at which prenatal stores become depleted, circumstantial evidence has to be used. Available evidence suggests that the older the exclusively breastfed infant the greater the risk of specific nutrient deficiencies. The inability to estimate the proportion of exclusively breastfed infants at risk of specific deficiencies is a major drawback in terms of developing appropriate public health policies. Conventional methodologies require that a nutrient’s average dietary requirement and its distribution are known along with the mean and distribution of intakes and endogenous stores. Moreover, exclusive breastfeeding at 6 months is not a common practice in developed countries, and it is rarer still in developing countries. There is a serious lack of measurement, which impedes evaluation, of the human- milk intakes of 6-month-old exclusively breastfed infants from developing countries. The marked attrition rates in exclusive breastfeeding through 6 months postpartum, even among women who are both well nourished and highly motivated, is a major gap in our understanding of the biological, cultural and social determinants of the duration of exclusive breastfeeding. A limitation to promoting exclusive breastfeeding for the first 6 months of life is our lack of understanding of the reasons for the attrition rates. Improved understanding of the biological, socioeconomic and E X E C U T I V E S U M M A R Y In this review nutrient adequacy of exclusive breastfeeding is most commonly evaluated in terms of growth. Other functional outcomes, e.g. immune response and neurodevelopment, are considered when data are available. The dual dependency on exogenous dietary sources and endogenous stores for meeting requirements is also considered in evaluating human milk’s nutrient adequacy. When evaluating the nutrient adequacy of human milk, it is essential to recognize the incomplete knowledge of infant nutrient requirements in terms of relevant functional outcomes. Particularly evident is the inadequacy of crucial data for evaluating the nutrient adequacy of exclusive breastfeeding for the first 4 to 6 months. Mean intakes of human milk provide sufficient energy and protein to meet mean requirements during the first 6 months of infancy. Since infant growth potential drives milk production, the distribution of intakes likely matches the distribution of energy and protein requirements. The adequacy of vitamin A and vitamin B6 in human milk is highly dependent upon maternal diet and nutritional status. In well-nourished populations the amounts of vitamins A and B6 in human milk are adequate to meet the requirements for infants during the first 6 months of life. In populations deficient in vitamins A and B6, the amount of these vitamins in human milk will be sub-optimal and corrective measures are called for, either through maternal and/or infant supplementation, or complementary feeding for infants. The vitamin D content of human milk is insufficient to meet infant requirements. Infants depend on sunlight exposure or exogenous intakes of vitamin D; if these are inadequate, the risk of vitamin D deficiency rises with age as stores become depleted in the exclusively breastfed infant. The calcium content of human milk is fairly constant throughout lactation and is not influenced by maternal diet. Based on the estimated calcium intakes of exclusively breastfed infants and an estimated absorption efficiency of > 70%, human milk meets the calcium requirements of infants during the first 6 months of life.
  45. 45. N U T R I E N T A D E Q U A C Y O F E X C L U S I V E B R E A S T F E E D I N G F O R T H E T E R M I N F A N T D U R I N G T H E F I R S T S I X M O N T H S O F L I F E 2 cultural factors influencing the timing of supplemen- tation of the breastfed infant’s diet is an important part of advocating a globally uniform infant-feeding policy that accurately weighs both this policy’s benefits and possible negative outcomes. It is important to recognize that this review is limited to the nutrient needs of infants. No attempt has been made to evaluate functional outcomes that depend on other bioactive factors in human milk, or behaviours and practices that are inseparable from breastfeeding. Neither have the consequences, positive or negative, for mothers been considered. It is important that functional outcomes, e.g. infant morbidity and mortality, be taken carefully into account in determining the optimal duration of exclusive breastfeeding in specific environments. This review was prepared parallel to, but separate from, a systematic review of the scientific literature on the optimal duration of exclusive breastfeeding.1 These assessments served as the basis for discussion during an expert consultation (Geneva, 28–30 March 2001), whose report is found elsewhere.2 1 Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Geneva, World Health Organization, document WHO/NHD/01.08–WHO/FCH/CAH/ 01.23, 2001. 2 The optimal duration of exclusive breastfeeding: report of an expert consultation. Geneva, World Health Organization, document WHO/NHD/01.09–WHO/FCH/CAH/01.24, 2001.