Counseling the breastfeeding woman: diet and supplements for breast milk quality and quantity

VIDEO 16

Breastfeeding plays a crucial role in the health, growth and development of babies and has benefits for the mother too. Women may need some help to successfully feed their babies. They need support and reassurance as they learn this skill. Breastfeeding remains the superior form of infant nutrition and also serves as an extrauterine directive of immune development. The issues relevant to lactation success have changed as the world has changed. The ability to counsel breastfeeding women and a multiprong approach significantly impact her success, particularly in urban, low-income settings.

BACKGROUND

As stated by the WHO, investing in infant and young child nutrition is important as it helps improve survival and promotes healthy growth and development. Optimal nutrition during the first 2 years reduces morbidity and mortality and also the risk of chronic disease in adulthood, thus promoting sustainability of development.

Breastfeeding (or, when necessary, feeding expressed breast milk) is recognized as the normative standard for virtually all infants because of its health benefits to infants and their mothers. There is broad consensus on recommending exclusive breastfeeding for approximately the first 6 months and continued breastfeeding, along with the introduction of solid foods, up to 2 years after birth, and as long as it is mutually desired by parent and infant.

However, globally, despite extensive evidence that non-breastfeeding is associated with increased mortality and serious morbidity and other long-term adverse health outcomes, efforts at a national level to increase exclusive breastfeeding and rates of continued breastfeeding have, in general, had only modest effect. Over the period 2015–2020, only about 44% of infants of 0–6 months were exclusively breastfed. In the USA, more than 80% of birthing parents initiate breastfeeding, but fewer than 60% continue until 6 months postpartum and fewer than 40% are breastfeeding at 12 months. Exclusive breastfeeding is practiced by less than one-half of birthing parents at 3 months postpartum and only one-quarter at 6 months.

IMPORTANCE OF BREASTFEEDING COUNSELING

These facts stress the importance of breastfeeding counseling, which was recently highlighted by the guideline and evidence-informed recommendations of the WHO.

According to the guideline, breastfeeding counseling should be provided to all pregnant women and mothers of infants and young child, starting in the antenatal period, and continuing postnatally up to 24 months or longer. Face-to-face counseling or, if needed, remote counseling should occur at least six times, including before birth, immediately after birth and 12 weeks after birth, in the first 34 months, at 6 months and later. Breastfeeding counseling should be provided as a continuum of care, by appropriately trained healthcare professionals but also community-based lay and peer counselors is important. Particular attention should be paid to reaching those women that health services are not reaching, such as marginalized, stigmatized and geographically isolated women. The recommendations mention that counseling should anticipate and address important challenges and contexts for breastfeeding, and establish, in addition to skills and competencies, confidence among mothers.

Breastfeeding counseling should understand which factors affect parental decisions about infant feeding in all situations, which is essential to providing appropriate education and support. Counseling should take into consideration the multiple determinants and influences that are at work at structural, community, workplace and individual levels. Counseling should coordinate with key interventions and programs that aim at improving breastfeeding rates, such as parental education and support; breastfeeding protection, promotion, and support; baby-friendly hospitals support; community and peer support mobilization.

Diet

The diet of breastfeeding mothers should include increased calories and macronutrients that are needed to maintain energy and nutrient stores, while respecting the postpartum gradual weight loss. A daily supplementary amount of 400 calories is optimal from birth to 12 months, allowing for meeting daily energy requirements of 2500–2800 calories during the first 6 months, slightly less thereafter, depending on height, BMI, activity, age and quantity of milk produced. Regular physical activity is the other major pilar of energy balance.

There is no need for a special diet during breastfeeding, except increased calory intake. The advice is to simply follow a healthy, well-balanced and varied diet, adapted to the living context. Each breastfeeding woman should be encouraged to build her own healthy eating style, based on a variety of foods and beverages. This includes foods from all groups: fruit, vegetables, grains, dairy, and proteinaceous foods. For example, half of a plate should ideally contain fruit and vegetables, optimally a variety of five; half of grains should be whole grains, and there should be high-fiber content. Protein-rich food consists of beans, pulses, fish and lean meat. Animal fat and sugar intake should be limited, as should processed food.

Calcium intake should be higher during lactation and reach approximately 1300 mg/day, compared to the usual recommended intake of 1000 mg/day. Calcium is contained in milk and dairy products, such as low-fat cheese and low-sugar yogurt, and is needed for infant bone mineralization and growth.

Drinking will generally spontaneously adapt to the necessary increase of liquid compartments, allowing for up to 750 mL milk production daily.

Breast-milk supply

Breast milk production is naturally stimulated by suckling and adapts to the baby’s needs. It is reasonable to try to satisfy the baby's demands as much as possible, without excess and by preserving sufficient rest time for the mother. Steady growth of the baby is the best sign that milk production is adequate. Usually, moderate maternal weight loss (e.g. 0.5 kg/week postpartum) does not affect breast milk production.

However, if necessary, the following steps can be taken to increase milk supply:

• Optimize lifestyle factors and self-care, targeting a healthy diet and reducing stress as much as possible
• Increase hydration by increasing the mother’s water intake
• Breastfeed more often, generally eight times a day or more, respecting the baby’s rhythms
• Offer both breasts at each feed, ensuring that the baby empties the breasts
• Massage the breasts while the baby is suckling
• If necessary, use a breast pump, eight or more times a day, possibly starting with a lactation consultant.

Maternal food allergies

Babies are rarely affected by maternal food allergies. Indeed, babies are less likely to develop food allergies if their mothers eat a diet including foods considered allergenic. Usual gastrointestinal functional symptoms in the infant are not related to allergy, although rare cases of cow’s milk or soy allergy do occur in babies, due to maternal diet, with symptoms often including blood in the stool.

Specific needs and supplements

The production of most nutrients is resilient during breastfeeding: this is true for fat, protein, carbohydrates and major minerals such as calcium, except in cases of major maternal undernutrition. However, milk content of some micronutrients (vitamin A, thiamin, riboflavin, vitamin B6, vitamin B12, selenium, iodine) may be insufficient. Supplements may be needed in some situations.

In the case of restricted diets (vegetarian or vegan), vitamin B12 supplements may be needed, typically in the case of a vegan diet.

Maternal vitamin D supplements may be needed to meet the 600 IU/day requirement. Vitamin D is available in vitD-fortified milk or vitD supplements (associated with calcium supplements, if needed). All breastfed babies should receive a supplement of at least 400 IU/day vitamin D, starting soon after birth, as breast milk vitamin D content is low.

Iron supplements may be needed for the mother in case of anemia; some breastfed babies may need some iron supplements before the age of 6 months.

Iodine should be supplemented in countries in which table salt is not iodized: supplements of 150 μg potassium iodide/day are needed.

An Omega-3 long chain polyunsaturated fatty acids (LCPUFA) intake of 200–300 mg/day is recommended, and this can be obtained from fish with low mercury content, such as cod, haddock, salmon and canned light tuna.

Medications

Almost all medications are safe during breastfeeding, with few exceptions. Generally, the benefits of breastfeeding outweigh the risks posed by drugs such as antidepressants or benzodiazepines used to treat mental disorders in breastfeeding mothers, in situations in which these medications cannot be avoided, or their dosing reduced.

Medications and drugs to be avoided include:

• Antineoplastics, radiopharmaceuticals, some anticonvulsants
• Illegal drugs (amphetamine, cocaine, phencyclidine, heroin)
• Cannabis (knowledge on safety is insufficient)
• Alcohol
• Caffeine (except in moderate amounts)
• Tobacco and vape

Medications that might affect milk production should also be considered, such as over-the-counter decongestants that contain pseudoephedrine, which should be avoided. Progesterone-only birth control pills or non-hormonal intrauterine devices are preferred.

For any specific information, the following databases may be consulted:

• NLM LactMed database (www.ncbi.nlm.gov/books/NBK501922)
• Mother to Baby (www.mothertobaby.org)
• List of common medications and other materials from the Infant Risk Center (www.infantrisk.com)

CONCLUSION

No specific qualitative changes in diet and behavior are required during breastfeeding, except for the adoption of a healthy lifestyle widely recommended elsewhere, in terms of diet, physical activity, active and passive environmental exposures, stress reduction and sleep quality. Food supplements may be necessary in specific situations.

Breastfeeding needs promotion and support with counseling. Global breastfeeding rates are increasing, possibly in association with the global efforts to promote and support breastfeeding. Every breastfeeding mother needs personalized protection and support.

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