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Lactation
By - Danone Nutricia India
Experts

The nutritional link between the mother and the child continues even after birth. The new-born depends solely on breast milk for nourishment for a few months and so it is extremely crucial for the growth of the infant. This milk contains hundreds to thousands of distinct bioactive molecules which protect the infant against infection and inflammation and contribute to immune maturation, organ development, and healthy microbial colonization. Also, a lot of physiological changes occur in the mother post-delivery. This phase is also known as puerperium, and the changes occurring in this phase include chills, afterbirth pains, lochia- which is a form of bloody discharge from the vagina), difficulty in urinating and passing stools, sore muscles, breast changes etc. and hence an alteration in diet becomes vital.

MNT in Lactation

  1. Energy: Exclusive breastfeeding is recommended for the first six months after delivery, with introduction of complementary foods and continued breastfeeding thereafter (WHO, 2001) 2. According to the Food and Agriculture Organisation, the energy requirement of a lactating woman is defined as the level of energy intake from food that will balance the energy expenditure needed to maintain a body weight and body composition, a level of physical activity and breastmilk production that are consistent with good health for the woman and her child, and that will allow economically necessary and socially desirable activities to be performed3. To operationalize this definition, the energy needed to produce an appropriate volume of milk must be added to the woman’s habitual energy requirement, assuming that she resumes her usual level of physical activity soon after giving birth. The ICMR recommends energy increase of 600 Kcal for the first six months and 520 Kcals for the next six months.
  2. Carbohydrates: The principal carbohydrate in human milk is lactose, a disaccharide that contains galactose joined by beta-linkage to glucose. In human milk, lactose is present in the average concentration of 70g/litre and it is second only to water as a major constituent. Compared with glucose, lactose provides twice the energy value per molecule. For the first six months of life, exclusive breast feeding is recommended .This time tailors the concentration of lactose to the maturing neonatal and infant gut, particularly while colonic microflora and pancreatic amylase production are developing. Hence mothers need to focus on having a combination of simple and complex carbohydrates while they are lactating, emphasising more on complex carbohydrates. Carbohydrates should make up for 55% of total calories, with a minimum of 100g/dayfor lactating mother. Their diet should also include 25g of dietary fibre/day. Insoluble fibre prevents fluctuating blood sugars and soluble fibre cures constipation and heartburn which is common after delivery. 5 
    Good sources: For a good combination of soluble and insoluble fibre, lactating mothers need to consume whole grain cereals, pulses, dals, vegetables, roots and tubers and fruits regularly. 
  3. Proteins: Protein needs are high during lactation both for the mother and the infant. Large amount of amino acids is needed by the new-born for the formation of new muscle, connective tissue and bone, and for synthesis of a numerous enzymes and hormones. Lactating mothers also need protein to recover from the physiological strain of pregnancy and childbirth. The ICMR (2010) recommends an additional 19 g/day to be safe allowance for a lactating woman during 0-6 months and an additional 13g/day for 6-12 months over and above the basic 1g/kg body weight4. It is also recommended that around 12-13% of total calories should come from proteins3.
    Good sources: Eggs, lean meat, fish, milk and milk products, pulses, soybean, nuts.
  4. Fats: During lactation, about one third of the fatty acids present in the milk are derived directly from the maternal diet. Although, the total amount of fat in breast milk is not influenced by mother’s diet, the composition of breast milk fat reflects the composition of the mother’s diet6. Hence it’s important to incorporate essential fatty acids like ALA, DHA, EPA in her daily dietary consumption. ICMR (2010) recommends 30g/day of visible fat for lactating mothers, which is around 10-12% of her total calorie intake.4     
    Good sources: Sources of Alpha linolenic acid (ALA) include vegetarian foods like flaxseeds, flaxseed oil, canola oil, soya beans, pumpkin seeds, walnuts, chia seeds etc.   
    Sources of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) include non-vegetarian foods like fatty fish (salmon, mackerel, tuna), fish oils, enriched eggs. Some algae and seaweed are vegetarian sources of DHA available in form of capsules.

Other Nutrients

Nutrient Recommendation Rationale Sources
Calcium 1200mg/d During lactation, there is daily secretion of calcium into the breastmilk which comes to about 10g per month7. If extra calcium is not consumed to meet the additional requirement, during 8 months of breastfeeding around 7% of calcium will be leached from the bones and used for milk production. Milk and milk products, Ragi(nachni), seafood (with bones), tofu, beans, dark green leafy veg, sesame seeds, cauliflower greens, rajgira, horse gram etc.
Iron 21 mg/d The baby is born with large reserve of iron as mother’s milk is not a good source of iron.During lactation, mother needs iron to compensate the loss occurring for production of milk. However due to amenorrhea, the iron requirement is compensated for and it remains the same as that of general population. However, if iron requirements are not being met with diet alone, supplementation becomes necessary. 8 Bajra, garden cress seeds, dill (shepu/suva), lentils, tofu, soybean, dates, egg yolk etc
Vitamin A 7600 mcg/d The additional needs during lactation are calculated on the basis of Vitamin A secreted in the breastmilk and also, keeping in mind the requirement of infants aged below 6 months. Liver, egg yolk, red and orange fruits and vegetables, green leafy vegetables
Vitamin C 80 mg/d The additional needs are calculated based on Vitamin C secreted in the breastmilk. The quantity of Vitamin C in 650ml of milk is about 3mg/dl and thus ICMR recommends additional 20 mg which makes it 80 mg per day during lactation.  Amla, guava, agathi, cabbage, coriander leaves, drumstick leaves, knol-khol greens, giant chillies (capsicum) green chillies
Vitamin D - Vitamin D deficiency is common and can lead to abnormal bone growth. Supplementing the mother is essential to prevent deficiency both in the lactating mother and the infant. It is suggested that both the mother and the baby get some exposure to the sunlight daily. 9 The requirements of Vitamin D don’t change during lactation; however, ICMR recommends that if there is not enough exposure to sunlight, supplementing with 400 IU of Vitamin D daily is crucial. 4 Exposure to sunlight, liver, fortified butter, fortified milk and other fortified foods.
Water A minimum of 8 glasses/day An increased intake of fluids is necessary for adequate milk production, since milk is a fluid. Water and beverages such as milk, coconut water and other liquids all add to the fluid necessary to produce milk.10 -

Galactagogues

Galactagogues are substances that stimulate milk production or milk supply. They are broadly classified into two types based on their origin and functioning:

  1. Synthetic galactagogues and
  2. Herbal galactagogues

Synthetic galactagogues: Galactagogues are medications that aid in initiating and maintaining adequate milk production. Most exert their pharmacologic effects through interactions with dopamine receptors, resulting in increased prolactin levels and thereby augmenting milk supply. Some examples of synthetic galactagogues are domperidone and metoclopramide.

Herbal galactagogues: Herbs and foods that have been observed to increase milk production are collectively known as herbal galactagogues.

Some of the examples include:

  1. Shatavari: Although researches and literatures fail to elaborate on benefits on herbal galactagogues, they have been used traditionally and are widely popular. Shatavari is taken by many Asian mothers as a plant extract or in powder form as it is believed to increase milk production.
  2. Garlic: Garlic has been traditionally used as a galactagogue. Studies have shown that babies fed on breastmilk of garlic eating mothers stayed fed longer and the production of milk was relatively higher. Additionally it also relieves the mother and the baby of gastrointestinal problems and enhances their immunity.
  3. Fenugreek seeds: Fenugreek seeds are most widely used herbal galactagogues, globally. This herb has been shown to increase breast milk production significantly.

Dietary Recommendations

  1. Promote exclusive breastfeeding for the first six months and encourage breastfeeding till two years or as long as one can.
  2. Colostrum, the yellow milk which is secreted in the first 2 days of delivery, is rich in nutrients and anti-infective factors and should be fed to infants.
  3. Exercising regularly and remaining physically active helps in maintaining ideal body weight. Breastfeeding is the best way to reduce post-partum weight gain and also reduces the possibility of infections.
  4. Increase water intake. It is important to have a glass of water each time the mother feeds the baby.
  5. Avoid caffeine and sugar since it is secreted in the milk and can agitate the baby, make him restless and cause disturbed sleep. Sugar can also contribute to weight gain both in the mother and the baby.
  6. Avoid tobacco (smoking and chewing), alcohol and drugs during lactation. There are numerous studies which highlight the impact of nicotine and alcohol consumption on the infant’s health and development. Some of the effects are:
    1. Nicotine: Nicotine causes fussy behaviour, breast refusal, excessive crying, and increased colic in mothers. It increases baby’s heart rate, risk of SIDS by affecting the way a baby can resuscitate during hypoxic episodes and interferes with normal infant lung development.
    2. Alcohol: Alcohol consumption affects milk production. Furthermore, some of the alcohol consumed by a lactating woman is transferred to her milk and thus consumed by the infant. This alcohol consumption may adversely affect the infant’s sleep and gross motor development and also influence early learning.
  7. Superfoods like these can be given to lactating mothers:
    1. Almonds: Almonds are packed with proteins-a nutrient nursing mothers require in abundance. They also contain various other nutrients like Vitamin B, Vitamin E, Copper, Magnesium, Zinc which all help in strengthening the new-born’s immunity and also enhance the pace of mother’s recovery post-delivery 15. It works efficiently to deal with post-partum depression and induces peaceful sleep in the baby.
    2. Milk and Milk Products: Milk itself and its derivatives like yogurt, cheese, paneer etc. deliver a boost of bone-strengthening Vitamin D along with Calcium. They are also packed with protein and Vitamin B complex, which help in cell formation and energy release.
  8. Daily meal plan for breastfeeding mothers:
Food Group Amount Examples
Cereals 8-9 servings Chapati, rice, rice flakes, nachni, semolina
Pulses 3-4 servings Lentil, Bengal gram, kidney beans
Vegetables 3-4 servings Green leafy vegetables like Spinach, Radish leaves, shepu etc and other vegetables like cauliflower, beetroot, cucumber etc
Fruits 2-3 servings Oranges, watermelon, strawberries, apples, pear etc
Milk and milk products 3-4 servings Milk, curd, paneer, cheese etc
Non veg foods 1-2 servings Egg, chicken, fish
Fats and oils 30g Oil, ghee, butter etc.

Recommended Dietary Allowance for Lactation (ICMR, 2010)

  RDA for a non-lactating woman 0-6 months 6-12 months
Energy (Kcal/d) Sedentary work- 1900, Moderate work- 2230, Heavy work- 2850 +650 +520
Protein (g/d) 55 74 68
Visible Fat (g/d) Sedentary work-20, Moderate work-25, Heavy work-30 30 30
Calcium (mg/d) 600 1200 1200
Iron (mg/d) 21 21 21
Zinc (mg/d) 10 12 12
Magnesium (mg/d) 310 310 310
Vitamin A (Retinol) (mcg/d) 600 950 950
Vitamin A (B- Carotene) (mcg/d) 4800 7600 7600
Thiamine (mg/d) Sedentary work- 1.0, Moderate work- 1.1, Heavy work- 1.4 +0.3 +0.2
Riboflavin (mg/d) Sedentary work- 1.1, Moderate work- 1.3, Heavy work- 1.7 +0.4 +0.3
Niacin Equivalent (mg/d) Sedentary work-12, Moderate work-14, Heavy work-16 +4 +3
Vitamin B6 (mg/d) 2.0 2.5 2.5
Ascorbic acid (mg/d) 40 80 80
Dietary folate (mcg/d) 200 300 300
Vitamin B12 (mcg/d) 1.0 1.5 1.5

References:-

  1. Ballard, O., & Morrow, A. L. (2013). Human Milk Composition. Pediatric Clinics of North America, 60(1), 49-74. doi:10.1016/j.pcl.2012.10.002
  2. WHO | The World Health Organization's infant feeding recommendation. (2001). Retrieved from http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/
  3. FAO | Human Energy Requirements. Retrieved from http://www.fao.org/3/a-y5686e.pdf
  4. ICMR | Nutrient Requirements and Recommended Dietary Allowances (2010) Retrieved from http://www.icmr.nic.in/final/RDA-2010.pdf
  5. James ML & Mark D. (2010) Effects of Dietary Fiber and Its Components on Metabolic Health. Nutrients, 2(12): 1266–1289
  6. Jan R & Karen W. Breastfeeding and Human Lactation. 507-508
  7. NIN| Dietary Guidelines for Indians (2011). Retrieved from http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf
  8. M Zimmermann M.D. (2011) Handbook of Nutrition- Micronutrients in the Prevention and Therapy of Diseases. 134-138
  9. B. Srilakshmi. (2009) Dietetics. Nutritional and Food Requirements for Lactating Women. 103-9
  10. Oxford Journals | Nutrition in Pregnancy and Growth of the Fetus. Retrieved from http://www.oxfordjournals.org/our_journals/tropej/online/mcnts_chap4.pdf
  11. Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding Women: A background paper. Retrieved from http://www.health.govt.nz/publication/food-and-nutrition-guidelines-healthy-pregnant-and-breastfeeding-women-background-paper
  12. Nicotine in Breast Milk. (1934). Journal of School Health, 4(4), 15-16. doi:10.1111/j.1746-1561.1934.tb09597.x
  13. Pearson PG. (2016). Nicotine in Breast Milk. Breastfeeding Support. doi:10.1075/ps.5.3.02chi.audio.2f
  14. Manella J. Alcohol' s Effect on Lactation. Retrieved from http://pubs.niaaa.nih.gov/publications/arh25-3/230-234.htm .  
  15. Eat for Health Australian Dietary Guidelines. (2014). Retrieved from https://www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55a_australian_dietary_guidelines_summary_book.pdf  

This article is contributed by Nurture Health Solutions