NUTRITION FOR NURSING MOTHERS

Transcription

1 NUTRITION FOR NURSING MOTHERS Navigate the Learning Management System To take notes download the Powerpoint slides from the Attachments in the upper right corner. To exit the lesson and resume later in the same place, click the Course Home button above right. 1

2 + NUTRITION FOR NURSING MOTHERS April Fogleman, PhD, RD, IBCLC + April Fogleman, PhD, RD, IBCLC 2

3 + Course objectives Describe a well balanced diet for nursing mothers Discuss the effects of maternal diet on milk production & composition Identify weight loss strategies for the breastfeeding mother Discuss controversial or recent nutrition interest topics + 3

4 + Helpful Terminology Recommended Dietary Allowance (RDA) is the average daily dietary intake of a nutrient that is sufficient to meet the requirement of nearly (97-98%) healthy persons. all Adequate Intake (AI) for a nutrient is similar to the ESADDI and is only established when an RDA cannot be determined. Therefore a nutrient either has an RDA or an AI. The AI is based on observed intakes of the nutrient by a group of healthy persons. Tolerable Upper Intake Level (UL) is the highest daily intake of a nutrient that is likely to pose no risks of toxicity for almost all individuals. As intake above the UL increases, risk increases. Estimated Average Requirement (EAR) is the amount of a nutrient that is estimated to meet the requirement of half of all healthy individuals in the population. Definitions of above terms taken from: + 4

5 + Human Milk Production Mothers worldwide produce an average of ml (25-27 oz) per day Remember, the stimulation and the removal of milk from the breast are the main factors that drive milk production (you know, this is a simplified explanation) (Marasco & West, 2009) (IOM, Nutrition During Lactation, 1991) + Normal Physiologic Process Evidence indicates that women are able to produce milk of sufficient quantity and quality to support growth and promote the health of infants even when the mother s supply of nutrients is limited Subcommittee on Lactation, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board, Institute of Medicine, National Academy of Sciences,

6 + Normal Physiologic Process It is recommended to be alert to maternal energy & nutrient intakes if intake is limited.due to food preferences or lack of resources.she may be deficient in some nutrients or deplete her stores. Ideally, nutrients are from foods and not dietary supplements Production is not influenced by fluid intake. (IOM, Nutrition During Lactation, 1991) (Mannel, 2013) + Normal Physiologic Process Concentrations of minerals that are not affected by dietary intake Calcium, Phosphorus, Magnesium, Sodium, Potassium Dietary intake of Vitamin B6, Vitamin D, Selenium and Iodine do affect concentration in human milk. Concentration of some nutrients may be produced at the expense of maternal tissue especially, for Folate(Folic Acid) & Calcium Different Fatty Acids in milk will vary according to mother s diet. (IOM, Nutrition During Lactation, 1991) 6

7 + Changes in the Lipids of Human Milk The type of fat consumed A diet rich in PUFAS will cause an increased percentage of PUFAS in the milk without affecting the total fat content When fish oil is given during pregnancy, it significantly increases omega-3 fatty acids and IgA as well as other immune factors (Dunstan JA, Roper J, Mitoulas L, et al The effect of supplementation with fish oil during pregnancy on breast milk immunoglobulin A, soluble CD 14, cytokine levels and fatty acid composition, CLin Exp Allergy (34) ) + Potential Barriers Mothers may voice concerns that may be a barrier to choosing breastfeeding There are too many diet rules I really don t eat well enough It takes too much time to eat well I really want to loose weight right after pregnancy 7

8 + THINKING CHALLENGE WHAT FACTORS MAY PUT A NURSING MOTHER AT RISK FOR INADEQUATE NUTRITION? + General Nutrient Demands Increased demands-energy (calories), Protein, Carbohydrate Increased demands for some minerals- Calcium( 18yo), Zinc, Iodine, Selenium Iodine & Selenium levels in milk correspond to maternal intake Calcium, Sodium, Potassium, Iron, Zinc, Fluoride, Magnesium and other minerals levels in milk tend to be consistent 8

9 + General Nutrient Demands Fat soluble vitamins-a, D, E, K stored in maternal fatty tissue RDA for A, E Well nourished Mom may have milk with an insufficient amount of D & K Vitamin D - RDA has been increased Vitamin E - maternal stores probably used Water soluble vitamins B and C Milk levels decreased if mother s diet is inadequate Levels can increase with intake (Hale & Hartmann, 2007) (Riordan, 2010) + Caloric Demands ~ 2700 kcal/day (Range of kcal/d) 45 65% Carbohydrate 10-35% Protein 20-35% Fat Milk production requires ~ 670 kcal/day 500 kcal intake kcal fat stores/day in 1 st 6 months for production of ~780mL/d 400 kcal intake/day in 2 nd 6 months for production of ~600 ml/d 9

10 + Carbohydrate RDA Non-pregnant Nursing 130 g/d 210 g/d Estimated Average Requirement = 160 g/d Major carbohydrate in human milk is lactose, which is the 2 nd major constituent.. What is the most abundant constituent? + Carbohydrates Roles: Mother - major energy source, low intake may lead to fatigue, dehydration, energy loss (Riordan, 2010) Baby - supplies 40% of energy needs, used for brain development, aids in colonization of intestine Sources: Breads, cereals, grains, rice, pasta, fruits & vegetables (Walker, 2011) (Mannel, 2013) (Riordan, 2010) 10

11 + Protein RDA Non pregnant Nursing 0.8 g/kg/d 1.1 g/kg/d Usually, not difficult to meet this requirement Building block for organs, muscles, bones, antibodies, hormones, enzymes Milk protein concentrations are not associated with maternal protein intakes, even in malnourished populations (Hale & Hartmann, 2007, p. 378) + Fat 20 35% of dietary calories should come from fat Most variable component in milk Increases over the course of a feeding The shorter the time between feedings the higher the fat content Smoking decreases the fat content Concentrations of cholesterol & phospholipids in human milk remain stable regardless of dietary intake except during early days of lactation the levels are greater (Walker, 2011) 11

12 + Fats Roles for Baby s growth & development Supplies up to 50% of calories Needed for brain, retina and cell membranes Soft consistency of stools due to high concentration of fatty acids in human milk Preterm human milk has 30% higher fat content + Fats Sources: Consume more of Mono- and Polyunsaturated fats (help to decrease LDL) avocados, olives, walnuts, sunflower oil, canola oil, olive oil Consume less Saturated fats & Trans fatty acids (these increase LDL) such as red meats, cream, whole fat dairy foods, palm & coconut oils French fries, snack foods, baked goods, processed foods, stick margarines Trans fatty acids may increase mother s cardiovascular disease risk, little is known about risk to infant (Behan, 2006), (Riordan, 2010), (Mannel, 2013), (Walker, 2011), (Samour, 2007) 12

13 + OMEGA-3 FATTY ACIDS Omega-3 fatty acids EPA = eicosapentaenoic acid DHA = docosahexaenoic acid ALA = alpha-linolenic acid AI for nursing mothers = 1.3 g/day ( % of total calories) Long term benefits of early exposure to n-3 fatty acids on later child development are uncertain (JADA Sept. 2007) Average US intake = mg/d Average intake US pregnant/lactating women = 54 mg Interesting article...from K. Kendall-Tackett on Omega-3 in the perinatal period (Lammi-Keefe, 2006) (Blanchard, 2006) + OMEGA-3 FATTY ACIDS Level of DHA in human milk is dependent on dietary intake Sources Salmon, herring, cod, lake trout, DHA enriched eggs, shrimp, crab, lobster, scallops Mercury free fish oil supplements Risks & benefits during pregnancy, lactation, in infancy are unclear (JADA, Position Paper, 2007) Plant sources-have omega-3 ALA tend to poorly convert to EPA & DHA. milled flaxseed, flax oil, canola oil, walnuts, soybeans 13

14 + Safety of Fish FDA & EPA Advisory for women who may become pregnant, pregnant women, nursing women & young children Eat up to 12 ounces/week (~2 meals/week) a variety of fish/shellfish lower in mercury Salmon, shrimp, canned light tuna (limit white albacore to 6 oz/week), pollock, catfish, cod, clams, haddock, scallops, lobster + Safety of Fish DO NOT eat Shark, Swordfish, King mackerel, Tilefish, Shark Concern: methylmercury can be damaging to nervous system & brain development Check advisories about the safety of locally caught fish Resources: dvice_index.cfm#local Useful information: 14

15 + Calcium Basics RDA Non-Pregnant & Nursing yo 1300 mg/d yo 1000 mg/d ~ mg/d secreted into human milk Sources Nonfat or low fat milk, yogurt, cheese, tofu (w/ calcium sulfate), kale, bok choy, any food fortified w/ 30% calcium such as orange juice (Behan, 2006) (Prentice, 2000) + Calcium Basics Increased demands for a breastfeeding teen as she is still growing. Milk is a good source of fluid, protein, Vitamin D & some B vitamins (Behan, 2006) Supplement suggested, if recommended by your health care provider : Calcium Citrate, Calcium Carbonate or Calcium Phosphate 15

16 + Calcium Basics Bone loss occurs even with adequate intake Reversal of bone density losses occur within 3-6 months of weaning (Kovacs, 2001) Which results in density for a well nourished multiparous woman The more babies and months a mother breastfeeds, the lesser the risk for osteoporosis (Mannel, 2013) + Vitamin D RDA Non pregnant & Nursing Infants to 1 yo (AI) 600 IU/d 400 IU/d AAP Recommendation: Oral supplementation of 400 IU/d to infants that are exclusively or partially breastfed beginning in the first few days of life Hollis & Wagner 2004: A maternal intake of 4000 IU/d could achieve substantial progress toward improving both maternal and neonatal nutritional vitamin D status (Wagner, 2008) 16

17 + Vitamin D Roles: Works w/calcium & Phosphorous to mineralize bones; tooth enamel formation At risk population subgroups Older persons living in institutions, those with dark skinned pigmentation Human milk : IU/L with average content of 26 IU in a mother with sufficient stores Sources: Sunlight, fatty fish, egg yolks, butter, foods fortified with Vit D such as milk, orange juice, margarine, cereals (Walker, 2011) (Behan, 2006) + Iodine +140 micrograms/d for lactation Levels decreased in milk of mothers who smoke Levels inversely related to milk per chlorate levels, an environmental contaminant Important for neonatal thyroid hormone stores & neurological development Vegans may be at risk of deficiency Some controversy on dietary intake & milk content Sources: iodized salt, seafood, dairy products (Hale & Hartmann, 2007) (Pittman, 2011) 17

18 + Selenium + 15 micrograms/d for lactation Contributes to making a specific protein in the body that plays a role in antioxidant enzymes, thyroid function Sources: Plants grown in selenium rich soils, some meat and fish Useful resource (Hale & Hartmann, 2007) + Iron Basics RDA Non-pregnant 14-18yo 15 mg/d 19-50yo 18 mg/d Nursing (if menses has not yet returned) 14-18yo 10 mg/d 19-50yo 9 mg/d Sources - red meat, fish, poultry, egg yolks, dried beans, dried fruit, Vitamin C rich food w/ meals improves iron absorption 18

19 + Iron Ideal to correct anemia before conception If menstruation returns during BF then iron demands are high, mother may suffer if inadequate replacement Secrete ~ mg/d in human milk. Maternal intake or iron serum levels do not correlate with content in human milk. (Hale & Hartmann, 2007) + Iron Full term infant should have sufficient iron stores for about 4-6 mos. Premature/LBW infants at greater risk 50% of iron in human milk is absorbed due to lactoferrin milk iron 7% of iron in formula absorbed Infants who are only partially breastfed should receive iron fortified formula Complementary Iron rich foods introduced around 6 mos. - meat, iron fortified cereal (Behan, 2006)(Morin, 2008)(Core Curriculum for Lactation Consultant Practice, 2013) (Baker, 2010)(Walker, 2011) 19

20 + Zinc Basics RDA Non-pregnant yo yo Nursing yo yo 9mg/d 8mg/d 13mg/d 12mg/d Colostrum is 8x richer in Zn than mature milk Levels usually consistent in milk Immune function, eyes, liver, muscle, skin Sources Meat, poultry, oyster, crab, shrimp, eggs, seeds, legumes (Behan, 2006) (Walker, Breastfeeding Management 2011) + Fluoride Basics AI (Adequate Intake) = 3 mg/d No increased requirement same recommendation for non pregnant & nursing No need for supplementary Fluoride in infant s first 6 months per AAP 6 months + may need supplement depending on fluoride concentration in water supply (AAP, 2005) (Food & Nutrition Board, Institute of Medicine, ) 20

21 + Vitamin B6 or Pyridoxine RDA Non pregnant yo yo Nursing yo 1.3 mg/d 1.2 mg/d 2.0 mg/d Nutrient most likely to be low in milk if diet inadequate Needed for RBC synthesis, metabolism of protein & fat Avoid mega-doses ( mg) as may decrease milk production Best way to increase is through dietary intake Sources: Meat, shellfish, poultry, eggs, beans, bananas, whole grains (Behan, 2006) (Hale & Hartmann, 2007) (Riordan, 2010) + Folic Acid or Folate RDA Non pregnant Nursing 400 mcg/d 500 mcg/d Needed for hemoglobin & new cell synthesis, neurological development Consistent levels in milk at mother s expense Human milk is a good source Maternal stores of folate in healthy women can become depleted in early postpartum Sources: Green leafy vegetables, beans, seeds, eggs, wheat germ, fortified cereals & grains (Behan, 2007) (Riordan, 2010) 21

22 + Alcohol Hale s 2010 Medications and Mothers Milk, 2010 classifies alcohol as L3 AAP maternal medication usually compatible with cautions about possible side effects Hale, 2010 excess levels may lead to drowsiness, deep sleep, weakness & decreased linear growth Beer should not be used as a galactagogue as it oxytocin release which corresponds to milk release (Hale, 2010) + Alcohol Passes readily into milk Peak levels in milk occur within minutes on an empty stomach within minutes consumed with food Clears in ~ 2-3 hours in a 120# woman Time clears the alcohol, not pumping Helpful summaries: (Hale, 2010) (Mannel, 2013) 22

23 + Caffeine <300 mg/d (moderate intake) does not seem to cause problem for most babies Coffee averages mg/8 oz Other sources: Soda, Green/Black Teas, Chocolate (theobromine) ~ % of maternal dose is available to baby via human milk + Caffeine Adults excrete in ~3-5 hours Metabolism much longer in younger babies, especially if preterm or ill May cause irritability or wakefulness Hale s 2010 an L2 rating (Hale, 2010) (Mannel, 2013) 23

24 + Artificial Sweeteners-Aspartame Aspartame Nutrasweet or Equal Metabolizes into 2 amino acids-phenylalanine & aspartic acid Hale s 2010 category L1 L5 if infant has PKU + Artificial Sweeteners-Sucralose Sucralose Splenda is processed from table sugar, indigestible FDA approved as general purpose sweetener Splenda website states All FDA-required studies to support the safety of sucralose during pregnancy and nursing have been performed sucralose is suitable for use by everyone, including pregnant and nursing women. 24

25 + Artificial Sweeteners-Stevia Stevia Sweeteners FDA granted GRAS (Generally Recognized As Safe) in 2008 (Not approved - whole leaf stevia, crude extracts) Stevia sweeteners-highly refined Plant native to South America x sweeter than sugar Calorie free (Facts About Low-Calorie Sweeteners, International Food Information Council, 2009) + Summary of Sweeteners 25

26 + ACTIVITY : LACTMED SEARCH Search LactMed for further details on artificial sweeteners. Aspartame, Sucralose, Saccharin, Acesulfame Caffeine, Alcohol + Sensible Weight Loss Breastfeeding women lose more weight than non-breastfeeding Breastfeeding >6 mos & exclusively, more likely to see greater loss Safe weight loss = #/week after the 4 th week postpartum Suggested to not go less than 1800 kcal/day Be alert to Calcium, Zinc, Magnesium, Vit B6, Folate intake may need a multivitamin/mineral supplement (Mannel, 2013) (Behan, 2006) (ADA Position Paper, Promoting and Supporting Breastfeeding, 2009) 26

27 + Sensible Weight Loss Best results Diet & Exercise Balance caloric intake with level of physical activity Moderate exercise does not seem to have adverse effects on human milk volume/composition A positive note of support to Mothers from Dr. Jay Gordon, MD, FAAP, IBCLC see (Mannel, 2013) + Sensible Weight Loss If exercise intensity very high and prolonged may increase the lactic acid levels in human milk not harmful to infant Strenuous exercise (>1 hr/d) should be alert to her caloric needs Sour/bitter taste to milk Breastfeed before exercise Maintain adequate fluid intake (Clapp, 2002) (Mannel, 2013) (Amorim, 2007) (Physical Activity Guidelines for Americans, 2008) See 27

28 + LOW CARBOHYDRATE DIET No published studies of effects on maternal health or milk volume/composition grams/d considered a mild restriction for a low carb diet Carbs are needed by the brain for energy & for milk production (lactose) When you reduce your carbohydrate intake your body starts to convert fat for energy creating ketone bodies + LOW CARBOHYDRATE DIET Possible risks/concerns: Change taste/smell of milk Increased maternal plasma lipids Decreased milk supply Deficiencies in nutrients/fiber (Heinig, 2004) (Doberne, 2004) 28

29 + VEGETARIAN DIETS The breast milk of vegetarian women is similar in composition to that of non-vegetarians and is nutritionally adequate (ADA Position Paper : Vegetarian Diets, 2009) However, be alert.to Vegan diet NO meat, milk, poultry, eggs Potentially insufficient caloric intake May lead to inadequate D, B12, Zinc, Iron, Calcium, DHA, Iodine in mother Potential for D & B12 deficiency in infant + VEGETARIAN DIETS Cases of malnutrition in breastfed babies have occurred from extremely restricted diets Baby may show signs of B12 deficiency before mother- weakness, refusing to eat, hypotonia, delayed development Recommended: 4 servings/day of B12 or a supplement of 2.6 mcg/d Fortified sources for mother. soy milk, tofu, fortified cereal, nutritional yeast or a supplement of 2.6 mcg/d (Mannel, 2013) (IOM, Dietary Reference Intakes 2011) (Behan, 2007) (Hale & Hartmann, 2007), (Riordan, 2010), (Penney, 2008) 29

30 + Nutrient RESOURCES + ACTIVITY use this website to help you plan a nutritious intake: a_food_icon_advancer_print.pdf 2700 calories (min. intake) Starch/Grains 12 Milk 4 Protein 9 Veg 5 Fruit 6 Fat calories (min. intake) Starch/Grains 7 Milk 3 Protein 7 Veg 4 Fruit 4 Fat 5 30

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