1. Pregnancy
And
Breast – Feeding
Mitra Nosratabady

2. INTRODUCTION:
 Breast milk provides sufficient calories and nutritive factors
to allow an infant to double its birth weight by six months
of age.
 Breast milk is a bioactive, complex fluid containing more
than 200 recognized substances varying in composition
between women, and from the same woman, depending
upon her stage of lactation.5
 Breast milk of women who deliver a premature infant is
higher in calories, fats, protein, immune factors, and anti-
inflammatory agents compared to full-term breast milk,
therefore, adaptive to the additional nutritional needs of
the premature infant.

3. Key Message: Making Milk is Easy
 Moms body is built for lactation
 Efficient nutrient utilization
 Diet, fluid intake only minimally important
“Stress” only minimally important
 Most women only use 2/3 of capacity!
 Baby takes about 2/3 of milk available
 Most who can gestate – can lactate

4. Table 1: Key Recommendations for Breastfeeding Women
from the Dietary Guidelines for Americans 200519
Moderate weight reduction is safe and
does not compromise weight gain of the
nursing infant.
Weight Reduction
Neither acute nor regular exercise
adversely affects the mother's ability to
successfully breastfeed.
Physical Activity
Nutrient needs during lactation are a function of the woman’s
nutrient needs and status, and her output of breast milk. Her
needs will be greater if she is feeding twins or triplets, and less if
she is only partially breastfeeding an infant who is also receiving
formula or complementary solid foods.

5. What's New?
Exercise during lactation will not only improve the mother’s cardio
respiratory fitness but may increase the amount of essential fatty acids in
her breast milk.
California Food Guide Maternal Nutrition During Lactation
Chapter 8: Maternal Nutrition During Lactation

6. Postpartum Weight Loss:
 Weight loss in the first six months postpartum is normally 0.5-1.0
kg (~1-2 pounds) per month; however, not all lactating women lose
weight. Overweight women can lose up to 2.0 kg (~4.5 pounds) per
month without adverse effects on milk production.5
Intentional weight loss should not be attempted until two months
postpartum, and then at a rate of no more than 2 kg (~4.5 pounds)
per month, consuming a diet of at least 1,800 calories per day.5 This
loss should be managed with a combination of changes in food intake
and increased physical activity.

7. Nutrition and Lactation
Which aspects(situation) of diet are particularly important for women
who are breast-feeding?
100ml milk=(67kcal)/needs 85kcal food / for 6months 750ml(550-
1200)who=(750-600-500)
It has been calculated that breast-feeding carries a daily energy
cost of 650 kcal.
However, some of this is obtained by using up fat stored during
pregnancy for this purpose.
Consequently, women who exclusively breast-feed for 3–4
months need an extra 500 kcal/day, on average, which
corresponds to an average milk output of 750 ml/day.
Assuming that this extra energy is obtained via consumption of
a balanced and varied diet, the additional needs for essential
vitamins and minerals will also be met.

8. • Obese and overweight may not need entire to add
the extra calories
Energy
• Estimate need to produce
850 ml/day
• 600 kcal/d
• 80% efficiency E of food
• 750 kcal/day
• Fat stores of pregnancy may
provide 1/3
• + 500 kcal above
non lactating
women

9. Nutrition during lactation
Lactating mother’s produce normally about 750 ml of milk daily
Protein requirement:70%pr of food alter pr of milk to
produce 100 g milk-the need for extra protein is 2,4 g
The increment of protein allowance:
RDA: 25 g/day extra pr / for the first 6 month of full
lactation
To prevent dehydratation: at least 2-3 litre water is also need each
day for milk production
Energy requirement: ~500 additional calories but about 150 kcal is
supplied by extra fat, accumulated during pregnancy
Keep in mind!
In menu planning guidelines: fluids, dairy products, fruits and
vegetables are emphasized

10. some helpful nutritional guidelines:
Calcium:
• Calcium is very important to everyone but especially
when pregnant or breastfeeding because studies have
shown that calcium is drawn out of your bones during
pregnancy and lactation.
• The recommended daily allowance is 1,600mg daily;
which is 2-4 servings of milk products.
• Some good sources of calcium include yogurt, milk,
cheese, broccoli, watercress, oranges, almonds, tofu
and dark leafy greens.

11. Iron:
 Iron is important during pregnancy and postpartum. A lack of iron
in your blood can cause you to feel weak, light headed, tired, have
a loss of appetite, or be more likely to get colds and flu.
 Continuing to take your prenatal vitamins will help keep your iron
levels up but the best way to have enough iron in your blood is to
eat foods that are high in iron.
 Here is a list of foods- red meat, lamb, turkey, chicken, pork and
fish, kidney beans, dried beans and peas, whole grain breads and
iron fortified cereals, greens, broccoli, baked potato with skin,
raisins, and dried fruit.

*** High vitamin C foods/beverages along with high iron foods
help your body absorb iron easier, so drink a glass of 100% fruit
juice with your meal.

12. Folic Acid:
 Folic acid is very important if you could potentially become
pregnant. Folic acid is a B-vitamin, when taken one month before
conception and throughout the first trimester reduces the risk of
neural tube defects.
 The recommended amount of folic acid is 400 micrograms daily
which can be consumed in a vitamin supplement or by eating
foods high in folic acid.(tebaco –alchol)
 Breakfast cereal are especially high in folic acid, many contain
100% of the daily value, enriched pasta, rice, breads, flour and
other grains have been fortified with folic acid. Fruits, green leafy
vegetables, dried beans and legumes also contain folic acid.

13. Vitamins:
It is recommended that breastfeeding women continue to take
prenatal vitamins.
Eating lots of fruits and vegetables will also help you get all the
vitamins and mineral you need.
Vitamin D is important to your baby's bone growth.
It is now recommended that ALL infants and children have a
minimum daily intake of 400 IU of Vitamin D beginning soon after
birth.
Discuss questions and concerns about Vitamin D with your baby's
doctor. Vitamin D is found in fish, milk, eggs and butter.
Caffeine:
Caffeine should be limited to 2 servings or less daily. Caffeine is
found in coffee, soft drinks, tea, some medications and chocolate. If
your baby seems unusually fussy or wakeful you may want assess
how much caffeine you are consuming.

14. •© 2004 American Society for Clinical Nutrition
Vitamin D requirements during lactation: high-dose maternal
supplementation as therapy to prevent hypovitaminosis D for both the
mother and the nursing infant1
•Bruce W Hollis and
•Carol L Wagner
+ Author Affiliations
•1From the Division of Neonatology, Department of Pediatrics, Medical
University of South Carolina, Charleston, SC.
We conclude that the current DRI of 400 IU/d vitamin D for
lactating mothers is irrelevant to the vitamin D nutritional status of
mothers and nursing infants. Maternal vitamin D intakes of ≥4000
IU/d appear to be safe and to provide sufficient vitamin D to
ensure adequate nutritional vitamin D status for both mothers and
nursing infants. Additional detailed studies will be required to
determine the optimal vitamin D supplementation regimen for
lactating women(safe level)

15. My Pyramid Education Framework provide a basis for
dietary guidance for healthy individuals:18
(1) Variety—Eat foods from all food groups and subgroups.
(2) Proportionality(‫—تناسب‬Eat more of some foods (fruits, vegetables,
whole grains, fat-free or low-fat milk products), and less of others
(foods high in saturated or trans fats, added sugars, cholesterol salt,
and alcohol).
(3) Moderation—Choose forms of foods that limit intake of saturated
or trans fats, added sugars, cholesterol, salt, and alcohol.
(4) Activity—Be physically active every day.

16. Serving Sizes and Food ChoicesRecommended #
of Servings
Food
Groups
A 1 ounce equivalent is: 1 slice whole grain
bread, 1 cup dry cereal, ½ cup cooked cereal,
rice, pasta 1 roll, pancake, small tortilla ½ bagel
7-10 choices of
these 1 ounce
equivalents
Grains
Raw or cooked vegetables such as carrots,
broccoli, sweet potatoes, spinach, pumpkin,
squash, peppers, tomatoes, greens, cabbage,
snow peas, leafy greens, 100% vegetable juice,
corn, potatoes, legumes. Aim for these amounts
each week: 3 cups dark green veggies, 2½ cups
orange veggies, 3½ cups legumes, 7 cups starchy
veggies, and 8½ cups of other veggies
3½ cupsVegetables
Choose fresh, frozen, canned fruit or 100% juice.
Medium whole fruit= ½ cup ½ cup dried fruit= 1
cup fresh fruit
2 cupsFruits
Table 2: Daily Food Choices for Lactating Women18, 19 (2200-2800 calories)*

17. Serving Sizes and Food ChoicesRecommended #
of Servings
Food Groups
1 cup low-fat or fat-free milk or yogurt 1 ½ ounces cheese 2
ounces of low-fat cheese 1 cup pudding or custard made with
milk 1 ½ cups frozen yogurt or ice cream 1 cup calcium- fortified,
lactose-free milk or soy milk
3-4* of these
choices
*4 for teens
Milk
A 1 ounce equivalent is: 1 ounce of cooked lean meat, poultry, or
fish 1 egg ½ cup cottage cheese ¼ cup cooked dry beans, peas,
lentils ¼ cup tofu 1 Tablespoon of peanut butter ½ ounce nuts or
seeds
6-7 choices of
these, 1 ounce
equivalents
Meat &
Beans
Vegetable oil, soft margarine, mayonnaise, salad dressing6-8 teaspoonsOils
Discretionary Calorie Allowance is the remaining amount of
calories in a food intake pattern, after accounting for the calories
needed for all food groups using forms of foods that are fat-free
or low-fat, and with no added sugars
290-426Discretionary
Calories
Table 2: Daily Food Choices for Lactating Women18, 19 (2200-2800 calories)*

18. Fluids:
 Drinking plenty of fluids is very important when breastfeeding.
Eight to ten glasses of fluids are recommended daily.
 Drink when you feel thirsty.
 Water, 100% juice and low fat milk are good fluids to keep on hand.
 Try to always have some water available when you are
breastfeeding. )balance+)
Snacks:
 One of the biggest problems mothers face when they have a new
baby is finding time for themselves.
 Make it a priority to take care of your self and find time to eat. It is
not only important for you but also for your baby.

19. Supplement and Herbs:
The FDA does not regulate supplements and herbs and therefore
are not recommended when breastfeeding without consulting your
health care provider.
Artificial Sweeteners:
 There is not evidence that artificial sweeteners are harmful when
breastfeeding.
 Of course there is one exception to this rule for mothers of infants
with Phenylketonuria (PKU) as aspartame contains phenylalanine.
 In general it is always a good idea to keep food additives to a
minimum.

20. Breast milk composition and Diet
• DHA levels of breast milk vary with diet. Increased amounts of
DHA have been found in the breast milk of mothers
consuming fish or fish oil, and with supplementation.
• Water soluble vitamins may vary with diet. Diets inadequate
in B12 or thiamin have been associated with case reports of
deficiency in infants. High intakes of Vitamin C, however, does
not appear to change the content of breast milk.
• Supplementation of fat soluble vitamins do not appear to
alter the content of breast milk
• Iron supplementation does not appear to alter the iron
content of breast milk

21. Diet, milk production, and milk composition
 There is a great variation in milk composition during a feed,
from feed to feed, and even between breasts.
 The impact of dietary variation and milk composition is
unclear.
 Overall milk composition remains relatively unaffected by diet
variations
 although there are reports to the contrary:
 DHA and EPA supplementation, vegan diet, drugs and
environmental contaminants,…..

22. Influence of diet on milk composition
 Protein-energy malnutrition impacts milk volume.
Composition remains relatively unaffected
 Water soluble vitamins move readily from serum to milk thus
dietary fluctuations are more apparent
B12 vegan, case report of beri-beri…..
 Fat soluble vitamin content not improved with
supplementation
 Fatty acid composition (DHA and ARA) altered by maternal
diet and supplementation

24. Yes, you might need to eat a little more — about an
additional 400 to 500 calories a day — to keep up your
energy.
To get these extra calories, opt for nutrient-rich choices, such as:
a slice of whole-grain bread with a tablespoon (about
16 grams) of peanut butter,
a banana or apple,
and 8 ounces (about 227 grams) of fat-free yogurt.

25. There's no need to go on a special diet while breast-feeding your
baby. Instead, focus on making healthy choices to help fuel your
milk production.
Opt for a variety of whole grains as well as fruits and vegetables.
Wash your fruits and vegetables to reduce exposure to pesticide
residue.
Eating a variety of different foods while breast-feeding will
change the flavor of your breast milk. This will expose your baby to
different tastes, which might help him or her more easily accept
solid foods down the road.
To make sure you and your baby are getting all of the vitamins you
need, your health care provider might recommend continuing to
take a daily prenatal vitamin until you wean your baby

26.  It's important for breast-feeding moms to stay hydrated. Be sure to
drink frequently, preferably before you feel thirsty, and to drink more
if your urine appears dark yellow.
 Have a glass of water nearby when you breast-feed your baby — or
aim to drink at least eight glasses of water or other liquids a day.
 Be wary of juices and sugary drinks.
 Too much caffeine can be troublesome, too. Limit yourself to no
more than 2 to 3 cups (16 to 24 ounces) of caffeinated drinks a day.
Caffeine in your breast milk might agitate your baby or interfere
with your baby's sleep

27.  Certain foods or drinks in your diet could cause your baby to become
irritable or have an allergic reaction.
 If your baby becomes fussy or develops a rash, diarrhea or congestion
soon after nursing, consult your baby's doctor. It could indicate a food
allergy.
 If you suspect that something in your diet might be making your baby a
little fussier than usual, avoid the food or drink for up to a week to see if
it makes a difference in your baby's behavior.
 Consider eliminating dairy products or other allergenic foods or
ingredients, such as :
Cow's milk, Eggs, Peanuts, Tree nuts, Wheat, Soy, Fish

28.  Some breast-feeding women say that avoiding spicy or gassy foods, such as
onions or cabbage, can help — but this hasn't been proved through research.
 Also, you might try eliminating or reducing the amount of caffeine in your diet.
 For help determining links between your diet and your baby's behavior, you
might keep a food diary. List everything you eat and drink, along with notes
about how your baby seems to react — if at all.
 If removing a certain food or drink from your diet has no impact on your baby's
fussiness, add it back to your diet and consider other possible culprits instead.
If you're concerned about your baby's behavior, consult your baby's doctor.
 Remember, there's no need to go on a special diet while you're breast-feeding.
Simply focus on making healthy choices — and you and your baby will reap the
rewards.

29. What causes a low milk supply during breast-feeding?
 Various factors can cause a low milk supply during breast-feeding,
such as waiting too long to start breast-feeding, not breast-
feeding often enough, and use of certain medications.
 Sometimes previous breast surgery affects milk production.
Factors such as premature birth, maternal obesity and insulin-
dependent diabetes can also affect milk production.
 But take heart. Although many women worry about low milk
supply, insufficient breast milk production is rare. In fact, most
women make one-third more breast milk than their babies
typically drink.

30. To boost(+) milk production:
Breast-feed as soon as possible. Waiting too long to start breast-
feeding can contribute to a low milk supply. Hold your baby skin to
skin right after birth and your baby will likely breast-feed within
the first hour after delivery.
Breast-feed often. For the first few weeks, breast-feed your baby
at least every two to three hours round-the-clock. Breast-feeding
less often can contribute to a low milk supply.
Be alert to feeding problems. It's OK for your baby to nurse on
only one breast at a feeding — but if this happens regularly, your
milk supply will decrease. Pump the other breast to relieve
pressure and protect your milk supply until your baby begins
taking more at each feeding.

31. Infant suckles
at the breast.
Stimulation of
nerve endings
in mother’s
nipple/areola
sends signal
to mother’s
hypothalamus/
pituitary.
Pituitary releases
prolactin and oxytocin.
Hormones travel
via bloodstream
to mammary gland
to stimulate milk
production and
milk ejection
reflex (let-down).
Copyright © 2003, Rev 2005 American Academy of Pediatrics

33. Foods to avoid when breastfeeding:
 There are no specific foods you should avoid when
breastfeeding. If you notice your baby is fussy often you may
want to consider what you ate 4-6 hours previously.
 Some foods that babies can be sensitive to are cabbage, beans,
broccoli and some times peanuts, cow's milk, eggs, wheat, fish,
citrus foods and other nuts if there is a strong family history of
allergies to these foods.
Drugs in Human Milk:
 Some medications (prescription and over-the-counter
medications, and all street drugs) will pass into the mother's milk.
 Breastfeeding mothers should check with their Lactation
Consultant and Physicians before taking any medications

34. Modification of infant health through
maternal diet
• DHA
• Allergy
• Colic

35. Allergies: Breastmilk
• May be protective due to sIgA and mucosal
growth factors
• Maternal avoidance diets in lactation remain
speculative. May be useful for some highly
motivated families with attention to maternal
nutrient adequacy.

36. • Breast milk is an optimal source of nutrition for infants through
the first year of life or longer.
• Those breastfeeding infants who develop symptoms of food
allergy may benefit from:
– a.maternal restriction of cow's milk, egg, fish, peanuts and
tree nuts and if this is unsuccessful,
– b.use of a hypoallergenic (extensively hydrolyzed or if allergic
symptoms persist, a free amino acid-based formula) as an
alternative to breastfeeding.
AAP: Breast milk and allergy

37. AAP statement on Drugs and Human
Milk
• Pediatrics 2001 108(3) 776-788
• 7 tables
1) cytotoxic drugs that may interfere with infant metabolism
2) drugs of abuse for which adverse effects on infants have been
reported
3) radioactive drugs requiring temporary cessation of nursing
4) drugs with unknown effects
5) drugs with some associated effects that should be used with caution
6) medications compatible with nursing
7) food and environmental agents that may have effects on breastfeeding

38. • Authors Conclusion: Exclusion of allergenic
foods from maternal diet was associated with
a reduction in distressed behavior among
breast fed infants <6 weeks of age.
Colic and maternal diet
• David Hill et al Effect of Low
allergen Maternal Diet on
Colic among breastfed
Infants: A Randomized
controlled Trial, Pediatrics
Vol 116 #5 Nov 2005 709-15