Breastfeeding 2006

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Breastfeeding 2006
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• Public health breastfeeding
• Maternal diet for lactation

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Healthy People 2010
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The resurgence of breastfeeding at the end of the
second millennium. (Wright and Schanler, J Nutr.
131, 2001)

• Between 1971 and 1995 increase was for all
  groups.
• Between 1984 and 1995 increase was in groups less
  likely to breastfeed (low income, low education,
  African American, WIC)
• Early resurgence of breastfeeding concurrent to
  natural childbirth and womens movement in
  white well educated families

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More recent increases associated with

• Increased knowledge of the benefits of
  breastfeeding by professionals (AAP 1997)
• Successful breastfeeding interventions -
  especially in WIC
• 47 of US infants on WIC
• early 90s brought increased WIC for
  breastfeeding promotion and increased maternal
  food package for BF

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Percentage of Children Ever Breastfed by State
Source 2003 National Immunization Survey,
Centers for Disease Control and
Prevention,Department of Health and Human
Services
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Percentage of Children Breastfed at 6 Months of
Age by State
Source 2003 National Immunization Survey,
Centers for Disease Control and
Prevention,Department of Health and Human
Services
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Percentage of Children Breastfed at 12 Months of
Age by State
Source 2003 National Immunization Survey,
Centers for Disease Control and
Prevention,Department of Health and Human
Services
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Who Breastfeeds? (Data source Mothers Survey,
Abbott Laboratories, Inc., Ross Products Division)
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Who Breastfeeds?, cont.
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Who Breastfeeds? NIS, 2002

• Statistically significant differences between
  groups for exclusive breastfeeding at 6 months
• White child (15) compared to Black (5)
• Eligible for WIC but not receiving (22) compared
  to on WIC (10)
• In day care at 6 months (11) compared to not in
  day care (15).College educated mom (19)
  compare to other education levels (11-12)
• Married (15) compared to unmarried (9)
• lt 100 poverty (11) compared to gt350 poverty
  (17)

Ruowei et al. Pediatrics, 2005
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Why do we care?

• Breastfeeding and the Use of Human Milk
• American Academy of Pediatrics, 2005

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• Human milk is species-specific, and all
  substitute feeding preparations differ markedly
  from it, making human milk uniquely superior for
  infant feeding.

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Health Benefits for Infant

• Lowered risk of infectious diseases in both
  developed and developing countries diarrhea,
  respiratory tract infection, otitis media,
  bacterial meningitis, botulism, UTI, necrotizing
  enterocolitis, bacteremia
• Enhanced immune response to polio, tetanus,
  diptheria, haemophilus influenza immunization
• Possible lowered risk of sudden infant death
  syndrome
• Possible lowered risk of diabetes (type 1
  2),leukemia, Hodgkin disease, lymphoma
• Probable enhanced cognitive development
• Provides analgesia to infants during painful
  procedures

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Health Benefits for Mother

• Possible reduction in hip fractures after
  menopause
• Less postpartum bleeding more rapid uterine
  involution
• Reduced risk of breast and uterine cancer
• Increased child spacing

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Community Benefits

• Decreased annual health care costs of 3.6 billion
  in US
• Decreased cost of WIC
• Decrease in costs associated with infant illness
  - parental time lost from work
• Less environmental burden (no cans, no
  transportation manufacturing)

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The Economic Benefits of Breastfeeding A Review
and Analysis. Jon Weimer. Food and Rural
Economics Division, Economic Research
Service,U.S. Department of Agriculture. Food
Assistance and Nutrition ResearchReport No. 13.,
2001
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Breastfeeding and Long Term Risk of Obesity for
the Infant
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Risk of Later Obesity Associated with Rapid
Weight Gain in Infancy
Age at Follow up (years) Odds Ratio
Stettler, 2002 7 1.38 (1.32-1.44)
Stettler, 2003 20 5.22 (1.55-17.6)
Toschke, 2004 5-7 5.7 (4.5-7.1)
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Breastfeeding studies Challenges

• No consistent definition of breastfeeding
• Mixture of prospective and cross sectional
  approaches
• Mixture of definitions of obesity and ages of
  follow-up
• Adjusted for wide variety of control variables
• Effects often seen in only one gender or ethnicity

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Breastfeeding as an Infant and Risk of Later
Obesity
Classification of Breastfeeding Classification of Breastfeeding Odds Ratio
Armstrong, 2002 Exclusive at 6-8 weeks 0.70 (0.61-0.80) 0.70 (0.61-0.80)
Bergmann, 2003 More than 3 months 0.46 (0.23-0.92) 0.46 (0.23-0.92)
Gillman, 2001 Exclusive or mostly 0.78 (0.66-0.91) 0.78 (0.66-0.91)
Hediger, 2001 Ever Exclusive 0.63 (0.41-0.96) 0.63 (0.41-0.96)
Liese, 2001 Any breastfeeding 0.66 (0.52-0.87) 0.66 (0.52-0.87)
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Breastfeeding Studies, cont.
Classification of Breastfeeding Odds Ratio
Parsons, 2003 More than one month Female 0.84 (0.67-1.05) Male 0.93 (0.74-1.17)
Toschke, 2002 Any breastfeeding 0.80 (0.66-0.96)
Von Kries, 2000 Ever exclusive 0.75 (0.57-0.98)
Von Kries, 2002 Any breastfeeding 0.91 (0.60-1.38)
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Large Breastfeeding Studies without Odds Ratios

• Eriksson, 2003 cumulative lifetime incidence of
  BMI gt 30Kg/m2 not associated with breastfeeding
• Li, 2003 Risk of BMI gt95 not significant at
  ages 4-8 or 9-18.
• Poulton, 2001 Risk of overweight not
  significant at 3,5,7,9,11,13,15,18,21 or 26 years.

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Grummer-Stawn, 2004

• Study included 12,587 US girls and boys served by
  WIC and Child Health Block Grant
• Follow-up was at 4 years
• Classification of exposure was by months
• Breastfeeding had protective effect in white
  non-Hispanic low income children, but not when
  all racial/ethnic groups were combined.

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Recent Reviews Meta-analysis

• Owen et al. Pediatrics. 2005
• 61 studies
• Odds ratio 0.87 (95 CI 0.85-0.89) for reduced
  risk of later obesity associated with
  breastfeeding compared to formula
• Arenz et al. Int J obes relat metab disord. 2004
• 9 studies met criteria
• Odds Ratio 0.78, 95 CI (0.71, 0.85) protective
  effect of breastfeeding for obesity
• Found dose response
• Harder et al. Am J Epidemiol. 2005

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Harder et al. Am J Epidemiol. 2005 (17 studies)
Length of Breastfeeding Odds Ratio for Risk of Obesity 95 CI
lt 1 1.00 0.65, 1.55
1-3 0.81 0.74, 0.88
4-6 0.76 0.67, 0.86
7-9 0.67 0.55, 0.82
9 0.68 0.50, 0.91
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Breastfeeding Obesity Support for the Evidence

• Secular trends
• Trend for increased breastfeeding is opposite
  that for obesity
• Dose Response
• Some studies find, others do not
• Plausible mechanisms
• Bioactive components of human milk
• Changing composition of human milk during
  feedings
• Lower energy and protein intake in breastfed
  infants
• Insulin response to feeding
• Differences in the feeding relationship

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Breastfeeding What can we say?

• Early studies flawed and inconclusive (Butte, Ped
  Clin N Amer, 2001)
• Some studies, especially cross sectional studies
  based on parental report years after infancy,
  found some protective effects (Toschke, J Pediatr
  2002, Gillman, JAMA 2001, Hediger, JAMA 2001)
• Prospective studies have mixed results.
• Any protective effects of breastfeeding may not
  be detectable in the face of other more powerful
  risk factors

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Dubois et al. Public Health Nutrition, 2003

• Social inequalities in infant feeding during the
  first year of life. The Longitudinal Study of
  Child Development in Quebec (LSCDQ 1998-2002)
• Social disparities in diet during infancy could
  play a role in the development of social and
  health inequalities more broadly observed at the
  population level.

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HHS Blueprint for Action for Breastfeeding - 2000

• Health Care System
• Worksites
• Family and Community
• Research

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Practices for Successful Breastfeeding Services
at Hospital and Maternity Centers
A written breastfeeding policy that is
communicated to all healthcare staff Staff
training in the skills needed to implement the
policy Education of pregnant women about the
benefits and management of breastfeeding
Early initiation of breastfeeding Education of
mothers on how to breastfeed and maintain
lactation Limited use of any food or drink
other than human breast milk Rooming-in
Breastfeeding on demand Limited use of
pacifiers and artificial nipples Fostering of
breastfeeding support groups and services
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Child Care

• It is also important that childcare facilities be
  supportive of breastfeeding. Childcare centers
  should make accommodations for mothers who wish
  to breastfeed their children or have their
  children fed expressed milk.

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Worksites
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Pubic Education and Support

• Access to lactation consultants and/or peer
  support
• School health education should include the
  benefits of breastfeeding for mother and child
• Campaigns should be directed at fathers
• Social marketing campaign breastfeeding is the
  normal way to feed infants in most places that
  mothers and infants go.

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Needed Breastfeeding Research

• Social, cultural, economic and psychological
  factors that influence infant feeding decisions
• Improve understanding of health benefits
  especially among disadvantaged children
• Monitor trends of incidence, duration,
  exclusivity, partial and minimal breastfeeding
  among minority and ethnic groups
• Compare cost effectiveness of breastfeeding
  promotion programs

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Research needs, cont.

• Role of fathers
• Impact of brief postpartum hospital stays
• Safety of over the counter meds
• Effects of breast implants on childhood disorders

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Pisacane et al. A controlled trial of the
fathers role in breastfeeding promotion.
Pediatrics, 2005.

• 560 mother/father dyads
• All mothers received breastfeeding support and
  advice
• 280 fathers were randomized to a 40 minute
  training session about management of
  breastfeeding
• At 6 months
• 25 of intervention group was fully breastfeeding
  compared to 15 of control group
• Significant differences also in any
  breastfeeding at 12 months, perceived milk
  insufficiency
• 24 of women who experienced problems in
  intervention group were still breastfeeding at 6
  months compared to just 4.5 of women with
  problems in control group.

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Maternal Diet and Breastfeeding
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Basics

• There is no one optimal set of rules for maternal
  diets
• Women may choose not to breastfeed if the
  recommended dietary limitations and requirements
  are perceived as too difficult to follow

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Basics

• A balanced diet without excessive
  supplementation is the most physiologic and
  economic way to ensure good milk.
• Ruth Lawrence, 1998

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Basics

• IOM
• Women are able to.produce milk of sufficient
  quantity and quality to support growth and
  promote the health of infant - even when the
  mothers supply of nutrients is limited.

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Maternal Diet and Milk Production

• In extreme famine and malnutrition milk supply
  does eventually stop
• In more moderate deprivation, like the Dutch
  famine, milk production decreased slightly, but
  was maintained at the expense of maternal tissue.
• Effects of deficiencies may start at 1500
  kcal/day

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Energy

• Wide variation between women their infants
• Dependent on maternal stores
• 1989 RDA 500 kcal/day over reference
• Energy sparing adaptations
• decreased BMR
• decreased postprandial thermogenesis
• decreased physical activity

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2002 DRI for Energy

• Lactation energy needs calculated as
• EER milk energy requirement - weight loss
• Baseline for women older than 18 2,403
• First six months of lactation for women older
  than 18 is 2,773
• Second six months of lactation for women older
  than 18 is 2,803

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2002 DRI for Energy

• BMR, BEE, TEF - current information is
  non-conclusive regarding effects of lactation.
• Physical activity tends to be lower during
  early lactation but highly variable beyond early
  period.
• Milk energy output increases during first 6
  months is highly variable for second six months
  depending on weaning.

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2002 DRI for Energy

• Mean milk production 0.76 for first six months,
  0.6 in second six months. Mean energy density of
  human milk is 0.67 kcal/g
• Mean kcals from milk output 483-538 kcal/day
• In general, well nourished women loose .8 kg per
  month in first 6 months.

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EER for Lactation

• 1st 6 months EER 500 - 170 (milk energy
  output minus weight loss)
• 2nd six months EER 400 - 0

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Mean Maternal Energy Costs of Lactation
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Symposium Maternal body composition, caloric
restriction and exercise during lactation (Dewey,
J Nutr, 1998)

• For women with adequate stores, moderate weight
  loss does not adversely affect milk energy
  output.
• Thin women will maintain milk energy output in
  the normal range as long as they are in neutral
  or positive energy balance.
• It is only when thin women are in negative
  balance that milk energy output will be affected.

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Maternal Energy Reserves gt x
500
Milk energy output Kcal/day
Maternal energy reserves lt x
0
negative
positive
Maternal energy balance (kcal/day)
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Symposium Maternal body composition, caloric
restriction and exercise during lactation (Dewey,
J Nutr, 1998)

• Protective factors when mothers are in negative
  energy balance
• a high level of aerobic exercise enhances body
  fat mobilization during lactation.
• prolactin levels rise with exercise and negative
  energy balance leading to mobilization of fatty
  acids from adipose tissue or diet for milk
  synthesis (increased mammary lipoprotein lipase)
• Frequency and intensity of infant sucking affect
  endocrine and autocrine regulation of milk
  synthesis.

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Randomized trial of the short-term effects of
dieting compared with dieting plus aerobic
exercise on lactation performance (McCrory, AJCN,
1999)

• 3 groups of breastfeeding women 12 weeks pp, on
  study for 11 days
• 35 energy deficit from diet alone (n22)
• 35 energy deficit from diet and exercise (n22)
• control group (n23)
• No significant difference in
• milk volume, composition, or energy output
• infant weight

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Randomized trial of the short-term effects of
dieting compared with dieting plus aerobic
exercise on lactation performance (McCrory, AJCN,
1999)
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Randomized trial of the short-term effects of
dieting compared with dieting plus aerobic
exercise on lactation performance (McCrory, AJCN,
1999)

• Interaction between group and baseline body fat
• diet only group milk energy output increased in
  fatter women decreased in leaner women
• Plasma prolactin concentration was higher in
  energy deficit groups than the control group.

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Lactation Risk of Maternal Obesity

• In the early postpartum period lactating women do
  not loose weight faster than women who do not
  lactate. (Gunderson, 2000)
• Exclusive lactation for several months may be
  associated with increased weight loss of 2 Kg in
  some women. (Dewey, 1993 Gunderson, 2000)
• In large populations of women, weight reduction
  associated with lactation is minimal. (Sichieri,
  2003)

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Impact of Breastfeeding on Maternal Nutritional
Status (Dewey, 2004)

• Higher quality studies find that degree of
  breastfeeding affects maternal weight loss at 3-6
  months.
• Effect is small and may not be detectable in
  studies that do not measure exclusivity and/or
  duration.

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The Impact of Maternal Lactation is Difficult to
Study

• Relationship between lactation and weight loss is
  confounded by smoking, return to work, and
  dieting.
• Protective biological mechanisms may preserve
  maternal fat during lactation in order to assure
  adequate energy stores.
• Maternal weight loss during lactation is highly
  variable and is associated with gestational
  weight gain, cultural practices, physical
  activity and food availability (Butte, 1998)

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Protein

• Protein content per volume is sufficient even in
  malnourished women
• Supplementation of malnourished women increases
  total milk volume, but doesnt increase of kcal
  from protein

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Cholesterol

• Fat globule membrane includes cholesterol and
  phospholipids
• Human milk has high levels of cholesterol
  formula has none.
• Proportions of cholesterol in human milk are not
  influenced by maternal diet.

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Fatty Acids

• Maternal diet has no effect on total fat
  content of milk, but does influence kinds of
  fatty acids.
• When mother is in energy balance, about 30 of
  fatty acids in milk comes from mothers diet.
• Mammary gland can synthesize n-9 fatty acids up
  to 16-C.

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Is FA composition of milk associated with risk of
obesity?

• Aihaur and Guesnet. Obesity Reviews. 2004
• N-6 PUFAs are potent promoters of adipogenesis
  and adipose tissue development
• Percent of US infants gt 95
• 1970s 4.0 (boys) 6.2 (girls)
• Early 90s 7.5 (boys) 10.8 (girls)

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Aihaur and Guesnet
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Essential fatty acid requirements of vegetarians
in pregnancy, lactation, and infancy (Sanders,
AJCN, 1999)

• Many vegans and vegetarians have diets high in
  n-6 fatty acids and low in n-3
• ratios of 151 to 201 of linoleic to a-linolenic
  have been reported

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Essential fatty acid requirements of vegetarians
in pregnancy, lactation, and infancy (Sanders,
AJCN, 1999)
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Essential fatty acid requirements of vegetarians
in pregnancy, lactation, and infancy (Sanders,
AJCN, 1999)

• Lower DHA levels have been observed in blood and
  artery phospholipids of infants of vegetarians.
• Recommendations
• avoid excessive intakes of linoleic acid
• recommended ratio of n-6 to n-3 is 41 to 101

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Carbohydrate

• Lactose concentration is very stable and is not
  affected by maternal diet

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Water

• Forced drinking is counter-productive
• Illingworth and Kirkpatric (1953) reported that
  mothers produced less milk and babies gained less
  weight when they were forced to consume 107 oz
  per day compared to mothers with ad lib intakes
  averaging 69 oz per day.

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Water

• When fluids are restricted, mothers will
  experience a decrease in urine output, not in
  milk.
• Lawrence, 1998

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Vitamins Minerals

• Allen. Am J Clin Nutr. 2005. Multiple
  micronutrients in pregnancy and lactation an
  overview.
• Maternal micronutrient status should be viewed as
  a continuum through periconceptual period,
  pregnancy lactation.
• Multiple micronutrient deficiencies occur
  simultaneously when diets are poor

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Allen, cont.

• Priority nutrients for lactation based on
  relation between maternal status and breastmilk
  composition
• Thiamin, riboflavin, B6, B12, vitamin A, iodine
• For these nutrients poor maternal status in
  pregnancy can lead to poor infant stores that are
  exacerbated by low breastmilk content in
  developing countries

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IOM Nutrient Recommendations

• Examined US nutrient densities at 3 levels of
  energy intake
• 2700 (RDA for lactation)
• 2200 (actual reported intakes)
• 1800 (minimal level that should be considered on
  a restricted diet during lactation)

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Low Nutrient Intakes at Given Energy Levels in US
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IOM Recommendations

• Lactating women should be encouraged to obtain
  their nutrients from a well-balanced varied diet
  rather than from vitamin-mineral supplements.
  Specifically

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• Eat a wide variety of breads and cereal grains,
  fruits, vegetables, milk products, and meats or
  meat alternates each day.
• Take three or more servings of milk products
  daily.
• Make a greater effort to eat vitamin A-rich
  vegetables or fruits often.
• Be sure to drink when you are thirsty. You will
  need more fluid than usual.
• If you drink coffee or other caffeinated
  beverages such as cola, do so in moderation. Two
  servings daily are unlikely to harm the infant.
  Caffeine passes into milk.

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IOM Recommendations

• There should be a well defined plan for the
  health care of the lactating woman that includes
  screening for nutritional problems and providing
  dietary guidance.
• Women who plan to breastfeed or who are
  breastfeeding should be given realistic, health
  promoting advice about weight changes during
  lactation.

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IOM Recommendations

• Health care providers should be informed about
  the differences in growth between healthy
  breastfed and formula fed infants.
• Steps should be taken to ensure adequate
  nutrition of all infants.