Breastfeeding Women and Vitamin Supplementation: Is Taking a Multivitamin Beneficial?
Simply put, yes. With the exception of during pregnancy, there is probably no other time in a woman’s life when her nutritional intake is as important as when she is breastfeeding her baby. In addition to eating a sufficient number calories from a well-balanced diet, taking a high quality vitamin/mineral supplement can help a nursing mom guard her health so that she can produce quality breast milk for as long as she desires to breastfeed her baby. If you are not convinced that nutritional supplements are beneficial for the health of breastfeeding women and their babies, here are a few ideas to consider:
1. Current research is calling into question the long-held belief that the fetus and the breastfed infant will be adequately nourished regardless of the nutritional status of the mother.
Virtually all medical professionals agree that good nutrition during pregnancy and lactation is vitally important for the health of the mother and the growth and development of her offspring. For this reason, pregnant women and nursing moms are encouraged to eat a nutritious, well-balanced diet. In addition, pregnant women are routinely directed by health care professionals to take a multivitamin (prenatal) supplement to “ensure” adequate intake of nutrients.
(Note: While pregnant woman are routinely “prescribed” prenatal vitamins, it is interesting to note that research conducted by Picciano and McGuire on the use of dietary supplements by pregnant and lactating women, revealed that there are “no consistent recommendations concerning dietary supplement use during lactation”, with the exception that the American Thyroid Society recommends that nursing women supplement with 150 mcg of iodine daily. (Am J Clin Nutr 2009; 89(suppl):685S-7S.) And, other recommendations seem almost to discourage nursing women from taking supplements. The Institute of Medicine’s most recent recommendations state that lactating women should be encouraged to obtain their nutrients from a well-balanced, varied diet rather than from vitamin and mineral supplements.)
But, despite the general consensus about the importance of the mom’s diet, there is still a widely held (and, therefore, widely disseminated) view among health professionals that unless the mom is severely malnourished, the fetus or breastfed infant will always be adequately nourished. This “ultimate parasite” view takes the position that the growing child will ensure that he/she gets proper nutrition by robbing the mom of all available nutrients, at the expense of the mother’s nutritional status, of course. Because of this, it has long been believed that only when the mother is severely malnourished will the health of her baby suffer. So, until very recently, dietary supplementation by pregnant and nursing women has been viewed as an insurance policy to protect the mom’s nutritional status, rather than a necessity for optimal development of the fetus or infant.
However, many scientists are now beginning to take issue with this parasite view. According to Steven H. Zeisel, “There is growing evidence that the fetus and young infant are not protected from the inadequate diets of their mothers. It appears that there are periods during development in which specific nutrients are required for optimal development. Scientists discovered the requirements for iodine, folate, choline, and DHA for optimal development because they thought to look at these specific components of the diet; there are likely to be many more critical nutrients when we cast a broader net in our research.”
As research in this area continues to evolve, it is becoming increasingly clear that the health of our offspring suffers when maternal nutrient intake is suboptimal, not just when there is stark nutritional deficiency. By encouraging pregnant and lactating women to take a vitamin and mineral supplement, we can help ensure that the necessary nutrients are available to the fetus and infant at the exact time that they are needed for optimal growth and development.
2. The typical American diet may not be adequate enough to maintain maternal stores of nutrients during breastfeeding.
Routine nutritional surveys reveal that the typical American diet is too high in calories, fats (especially saturated fats), sodium, and added sugar. Our diets are also too low in fiber, whole grains, fresh vegetables, and important nutrients. Furthermore, it is interesting to note that only about 30% of American women rate their diet quality as very good or excellent. (source: How Americans Rate Their Diet Quality: An Increasingly Realistic Perspective Christian Gregory Travis Smith Minh Wendt)
And, unfortunately, we don’t seem especially motivated to change our dietary intake, even when we are bombarded with information about the benefits of decreasing this or increasing that. Take the case of folic acid, for instance: Even with widespread attention focused on the importance of maternal intake of folic acid (and widespread fortification of foods with folic acid) to prevent neural tube defects, the intake of folic acid in women of childbearing age in the United States has declined in recent years. (Quinlvan EP, Gerfory JF III. Reassessing folic acid consumption patterns in the United States (1999-2004): potential effect on neural tube defects and overexposure to folate. AM J Clin Nutr 2007; 86:1773-9.
The bottom line is that many of us don’t have a particularly nutritious diet, nor do we appear to be especially motivated to improve our diet - even when we know it is important to do so. Now add to that the increased nutritional demands brought on by producing breast milk, and you end up with a significant number of nursing women who are at risk for depleting their reserves of vitamins and minerals, which can potentially increase susceptibility to illness . . . the last thing a new mom needs.
Yes, we should absolutely continue to encourage nursing women to eat a well-balanced, varied diet as recommended by the Institute of Medicine, but we also need to be realistic about the fact that a nursing mom may not do much better than the average woman in terms of the nutritional quality of her diet. As a result, nutritional supplementation should be viewed as mandatory for nursing women, not optional.
3. The nutritional quality of breast milk is impacted by the mother’s diet.
It is true that the caloric content and the proportion of macronutrients (protein, fat and carbohydrate) in human milk are relatively constant in all nursing women and at every feed. Per milliliter, breast milk contains approximately 4 grams of fat, 1 gram of protein and 7 grams of carbohydrates, and these proportions do not change even when the mother’s diet changes.
It is also well-documented in the scientific literature that a mother's diet (and her overall nutritional status) can influence the vitamin, mineral, and the essential fatty acid (EPA and DHA) composition of her breast milk, all of which impacts the overall nutritional quality of the breast milk, and ultimately the overall health of the breastfed infant.
Research shows that the B vitamin (specifically, thiamin, pyridoxine, and niacin) content of human milk is highly correlated with maternal intake of these vitamins, so low maternal intake results in breast milk that is also low in B vitamins. The reverse is also true: increasing maternal intake of B vitamins results in an increase in the B vitamin content of human milk. The story is the same for Vitamin D. Low maternal intake and stores of Vitamin D results in breast milk that is low in Vitamin D, and increasing maternal intake increases the Vitamin D content of breast milk (more information on Vitamin D below).
While the overall fat content of breast milk is relatively stable, the fatty acid composition changes depending on the mom’s diet. As a result, women with high intake of omega 3 fatty acids produce breast milk with larger concentrations of these fats. In recent years, much attention has been focused on the importance of the omega 3 fatty acid, docosahexaenoic acid (DHA) for brain development in the fetus and infant, as observational studies have shown that high DHA intake by mothers during pregnancy and lactation results in enhanced cognitive function in their children. But, due to warnings about fish intake during pregnancy, many pregnant women are reducing their intake of DHA, which is reflected in lower breast milk DHA concentrations. Statistics show that the DHA concentration of breast milk from US women is less than 0.2% of total fatty acids, whereas in some Chinese women it is 2.8% of fatty acids.
4. It is safer to supplement the mom than the baby.
In recognition of the widespread vitamin D deficiency among women and the health risks associated with low circulating levels of Vitamin D in all people (and specifically in infants), the American Academy of Physicians now recommends that all exclusively breast fed infants receive a daily supplement of 400 IU of vitamin D. Breast milk was never meant to be the primary source of vitamin D for our babies (as we are all intended to make our own vitamin D with exposure to sunlight), but as we continue to be cautious about exposure to sunlight, breastfed babies do not get enough sun exposure to make sufficient amounts of Vitamin D, nor do they receive enough of this crucial vitamin in breast milk. As a result, breast fed babies are at risk for vitamin D deficiency, which is the impetus for the AAP recommendation. (Note: Infant formula is manufactured to contain the supplemental dosage of Vitamin D).
But, new research indicates that by increasing the amount of Vitamin D that a mom takes in, the amount of Vitamin D in the breast milk will increase so that supplementation is no longer necessary. A 2004 study conducted by Dr. Carol Wagner (a neonatologist with a strong interest in breastfeeding and vitamin D) and Dr. Bruce Hollis (an internationally recognized expert on vitamin D and calcium homeostasis) determined that supplementing the mother with 2000-4000 IU vitamin D per day safely improved the vitamin D status of the mother and baby. A Finnish study conducted in 1986 showed that supplementing the mother with 50 µg (2000 IU) vitamin D per day was as effective for maintaining baby's vitamin D levels as supplementing the baby with 10 µg (400 IU) per day. All of the most current research on Vitamin D, as it relates to pregnancy and lactation, is beautifully summarized in Dr. Wagner’s book titled: New Insights into Vitamin D During Pregnancy and Lactation (Hale Publishing, 2010).
So, it seems that breastfeeding women are being hit with some mixed messages. At the same time that the AAP is calling for supplementation of all exclusively breast fed infants due to concerns about Vitamin D deficiency, the Institute of Medicine seems to be dissuading lactating women from taking supplements themselves.
As researchers continue to study what is meant by “optimal nutrition” during pregnancy and lactation, it is likely that additional recommendations concerning dietary supplements will emerge. So, when the next Vitamin D situation arises, are we going to encourage additional supplementation of the baby, or will we focus on improving the nutritional quality of breast milk via maternal supplementation first? By supplementing the mom, you guarantee that you will provide the breastfed infant with the most bioavailable form of the nutrient and reduce the risk of an accidental overdose of infant.
And, on a related note, for some specific nutrients, a case can be made that it is safer for a pregnant or nursing woman to take a supplement than to acquire the nutrient through a food source. Due to the growing recognition of the importance of the omega 3 fatty acids (EPA and DHA) for the proper development of the growing child, pregnant and lactating women are encouraged to increase their consumption of foods containing these fats, such as fish and shellfish. However, the United States Environmental Protection Agency has issued warnings about the safety of eating these foods due to the presence of high amounts of mercury. By taking a high quality, purified fish oil supplement, a woman can increase her intake of these important fatty acids (thereby increasing the amount of EPA and DHA in her breast milk) without the risk of exposing herself and her child to the toxic effects of heavy metals.
5. We want women to breastfeed because it is the normal way to feed our children, not because breast milk is perfect
As a result, we should not be afraid to suggest that a nursing mom take a nutritional supplement that could potentially improve the nutritional composition (i.e. quality) of her breast milk because we fear that she might then question the “perfection” of breast milk. Yes, breast milk is best for baby (and nutritionally superior to formula in many ways), but it is not necessarily perfect. It is simply normal, which is the best reason of all to breastfeed. And because breast milk is normal, it is a reflection of a woman’s normal diet and normal lifestyle.
Again, let’s look at Vitamin D. Scientific research shows that breast milk does not contain enough vitamin D to compensate for the fact that most infants do not get the appropriate amount of sun exposure to manufacture sufficient Vitamin D. As a result, the American Academy of Pediatricians is now recommending that all breast fed babies be supplemented with 400 IU of Vitamin D (note: it could be suggested that this recommendation sends a powerful message to nursing moms that their milk is inadequate, especially when infant formula contains “enough” vitamin D), even though research shows that if maternal intake of Vitamin D increased sufficiently, the amount of vitamin D in the breast milk would increase, thereby eliminating the need to supplement the baby.
And, looking again at essential fatty acids: we know that the intake of essential fatty acids (EPA and DHA) among women has declined in recent years, and as a result, the amount of these fatty acids present in breast milk has declined as well, while infant formula companies are actively marketing the fact that their products contain DHA in abundance.
If we as a society want to see breastfeeding rates increase, we need to work to switch the perception that breastfeeding is superior to formula feeding, as this perception suggests that formula feeding is normal and good enough. In her article titled Making Breastfeeding Normal (Leaven, Vol. 45 No 4, 2009, pages 4-8), lactation consultant Diane Wiessinger writes,
“Who, after all, is a "perfect parent"? Perfect, ideal, optimal -- every time we use those words to describe breastfeeding, we reassure the public that formula feeding is normal. Normal is everyone. Normal is safe. The perfection of breastfeeding is much easier to talk about than its normalcy, because perfection allows everyone to fall short without consequences.”
Even while being extremely rewarding and beautiful, breastfeeding, like all “normal” parenting activities, is also physiologically and emotionally demanding. Being afraid to suggest that a nursing mom take a dietary supplement during this “stressful” stage of life to help protect her health AND to improve the nutritional quality of her breast milk suggests that we are still beholden to the idea that we must glorify breastfeeding as ideal and perfect.
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