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Patient education: Health and nutrition during breastfeeding (Beyond the Basics)

Patient education: Health and nutrition during breastfeeding (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Jan 30, 2024.

BREASTFEEDING AND HEALTH OVERVIEW — Breastfeeding has many health benefits for both you and your baby. (See "Patient education: Deciding to breastfeed (Beyond the Basics)", section on 'Why is breastfeeding important?'.)

If you are breastfeeding, your body needs an increase in calories and nutrients in order to maintain your nutrient and energy stores while allowing for the gradual loss of weight gained during pregnancy. In most cases, the best way to get adequate calories and nutrients is to eat a healthy, well-balanced diet that includes fruits, vegetables, protein, grains, and a limited amount of fat, sometimes with a multivitamin supplement.

This article includes recommendations for calorie intake, vitamin and mineral supplements, and hydration, and guidelines for weight loss while lactating. Foods, drinks, and medications that should be limited or avoided are also discussed. General principles of a healthy diet are discussed separately. (See "Patient education: Diet and health (Beyond the Basics)".)

More information about the basics of breastfeeding and common breastfeeding problems is also available. (See "Patient education: Common breastfeeding problems (Beyond the Basics)" and "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)".)

NUTRITION AND LACTATION

Caloric recommendations — When you are not lactating, your energy, or calorie, needs depend on many individual factors, including your weight, height, activity level, and age. Examples of caloric needs for people of various body weights and average height are outlined in the table (table 1).

During lactation, your body's energy needs depend on the amount of nutrition that you are providing for your baby. If you are your baby's only source of milk, your body has the following additional energy needs:

From birth through 6 months after birth – Approximately 400 calories per day more than when you are not lactating. This number factors in the gradual loss of weight gained during pregnancy. The energy required for milk production is approximately 540 calories per day, 140 of which come from your body as you gradually lose weight in the months after giving birth (540 minus 140 = 400 calories per day). This recommendation assumes that your baby gets only your milk and no formula or solid foods. It also assumes that you gradually lose approximately 8.5 pounds (3.8 kg) over the first six months after birth.

From 6 to 12 months after birth – Approximately 380 calories per day more than when you are not lactating. This assumes that your baby gets only your milk (no formula), plus solid foods starting around six months of age. The additional calories depend on how much of your milk your baby is taking. It also assumes that you have lost the weight you gained during pregnancy and are maintaining a stable body weight.

If you have a healthy body mass index (BMI) and are of average height, your total energy needs during lactation are approximately 2500 to 2800 calories per day for the first six months after birth and slightly less thereafter. The numbers depend on your weight, height, activity level, age, and how much milk you are producing. In most cases, your appetite will adjust to meet your body's needs, so you won't need to count calories. (See "Patient education: Weaning from breastfeeding (Beyond the Basics)".)

Nutrition and milk composition — Even if you are not getting the recommended calorie or nutrient intakes, your body will most likely still be able to produce enough milk for your baby (unless you are severely malnourished). Your milk will also have the appropriate content for most nutrients, including fat, protein, and carbohydrates, and major minerals such as calcium.

However, your nutrition does affect milk content for some other vitamins and minerals (such as vitamin A, thiamin, riboflavin, vitamin B6, vitamin B12, selenium, and iodine). If you do not get enough of these vitamins and minerals through diet alone, you may need to take supplements to ensure good milk quality. If you eat a restricted diet (for example if you are a vegetarian or vegan), or have other concerns about getting enough nutrients, talk to your health care provider about whether you need any specific supplements. (See 'Vitamin and mineral requirements during lactation' below.)

Fluid intake — On average, if your baby is only getting breast milk, they will take approximately 25 ounces (750 mL) of milk per day. You might wonder how much extra fluid you should drink to stay hydrated. It is generally sufficient to drink when you are thirsty and to watch for early signs that you might not be getting enough fluids (eg, dark-colored urine, infrequent urination, dry mouth). It can help to keep a bottle of water or another healthy beverage nearby as a reminder to stay hydrated.

Food allergies or sensitivities — The foods you eat while you are lactating very rarely affect your baby. In fact, research suggests that babies are less likely to develop allergies if their mother eats a well-balanced diet, including foods that are considered "allergenic" (foods that many people are allergic to, such as nuts or shellfish). So, if your baby has symptoms such as fussiness or changes in their bowel movements, it's probably not related to your diet.

A few babies do have an allergy related to a food that you eat (usually cow's milk or soy). When this happens, the main symptom is blood in the baby's stool (poop) or, sometimes, persistent diarrhea or vomiting. If your baby has these symptoms, talk to their health care provider. They may suggest temporarily avoiding a certain food to see if this helps.

WEIGHT LOSS AND LACTATION — After birth, most lactating individuals lose the weight that they gained during pregnancy gradually. Losing a moderate amount of weight (for example, 1 pound [0.5 kg] per week) by eating less and/or exercising regularly probably will not affect your ability to produce an adequate amount of milk. (See 'Nutrition and milk composition' above.)

If you have had weight loss surgery, you can probably make enough milk as long as you have reached a stable lower body weight. However, weight loss surgery increases your risk for certain vitamin deficiencies, so it's particularly important to make sure to take your vitamin and mineral supplements as advised by your health care provider. Your baby should also be followed closely to make sure they are gaining weight appropriately, especially during the first few weeks of life, and to monitor them for possible vitamin deficiencies, especially vitamin B12. (See "Patient education: Weight loss surgery and procedures (Beyond the Basics)".)

VITAMIN AND MINERAL REQUIREMENTS DURING LACTATION — You should consume a healthy, well-balanced diet that includes dairy, meat and fish, and other vitamin- and mineral-rich foods. To ensure that you get all the vitamin and minerals you need, it is a good idea to take a multivitamin-mineral supplement while breastfeeding. The content of these supplements varies depending on the product. Be sure to choose one that contains at least 150 mcg of iodine. Taking a multivitamin-mineral supplement is particularly important if you follow a special diet (including a vegetarian diet). (See 'Iodine' below.)

You should take special care to consume an adequate amount of calcium and vitamin D to keep your bones healthy (this is also important when you are not breastfeeding). Most multivitamin-mineral supplements provide only part of your calcium needs. (See 'Calcium' below.)

Vitamin B12 — People who follow a vegan diet (ie, do not eat red meat, chicken, fish, eggs, dairy, or any other animal products) need to take a vitamin supplement that contains vitamin B12. This is always important but especially when you are lactating. Most commercially available multivitamins contain an adequate dose of B12.

Calcium — Pregnancy and lactation cause a temporary decrease in bone mass. However, lost bone is usually regained after you stop breastfeeding. This loss cannot be prevented by consuming additional calcium in food and beverages during pregnancy or lactation.

All adults should consume a minimum of 1000 mg of calcium a day prior to pregnancy as well as during pregnancy and breastfeeding; adolescent females should consume 1300 mg of calcium per day. These targets are the same as for those who are not pregnant or breastfeeding.

The primary sources of calcium in the diet are milk and other dairy products (such as hard cheese, cottage cheese, or yogurt) as well as calcium-fortified foods (such as orange juice, nondairy milks, or tofu). There are also smaller quantities of calcium in green vegetables such as spinach (table 2). If it is not possible to consume enough milk or other foods that contain calcium, it is reasonable to take a calcium supplement (table 3). (See "Patient education: Calcium and vitamin D for bone health (Beyond the Basics)".)

Vitamin D

For you – Both breastfeeding and non-breastfeeding adult females require an estimated 600 international units (15 micrograms) per day of vitamin D. Vitamin D is important to allow you to absorb calcium and maintain healthy bones.

Vitamin D-fortified milk is a good source of dietary vitamin D, providing approximately 100 international units (2.5 micrograms) per cup. You can also get vitamin D from a supplement (either vitamin D alone or calcium plus vitamin D). (See "Patient education: Calcium and vitamin D for bone health (Beyond the Basics)".)

For your baby – The American Academy of Pediatrics (AAP) recommends that all breastfed babies receive a daily supplement of vitamin D of 400 international units (10 micrograms) per day, beginning soon after birth. This is because breast milk is low in vitamin D, even if you are getting the recommended amount of vitamin D (600 international units or 15 micrograms daily) through your diet or supplements. Although vitamin D also can be made in the skin when it is exposed to sunlight, the AAP recommends that babies avoid direct sunlight exposure to reduce long-term risks of skin cancer. You can buy liquid vitamin D drops for babies at your pharmacy. (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Nutritional content of breast milk'.)

As an alternative to giving your baby vitamin D supplements, you can choose to take a high dose of vitamin D yourself (approximately 6000 international units or 150 micrograms per day). While there is some evidence that this is an effective way to fulfill your baby's daily vitamin D requirement, this practice is not recommended by the AAP as a routine approach and should be done only under guidance from a health care provider. If you are interested in trying this, talk with your baby's health care provider first.

Iron — The recommended dietary allowance of iron for lactating adults is 9 mg daily, compared with 18 mg for adult females who are not breastfeeding. Iron deficiency is the most common cause of anemia. (See "Patient education: Anemia caused by low iron in adults (Beyond the Basics)".)

If you are not anemic after delivery and are fully lactating (ie, exclusively breastfeeding), you probably don't need an iron supplement. This is because you will not resume your menstrual period for the first four to six months after birth, so you do not lose iron through menstrual blood.

If you are anemic after delivery, you should take an iron supplement; this may be provided via an over-the-counter or prescription iron supplement or by taking a prenatal multivitamin-mineral supplement. Most prenatal vitamin-mineral supplements contain more iron than is required during lactation, which causes abdominal discomfort for some people. If this happens, you can try taking a supplement that has lower amounts of iron (rather than a prenatal supplement) or you can take an iron supplement every other day. Talk to your health care provider about which type and dose is most appropriate for you. (See "Patient education: Anemia caused by low iron in adults (Beyond the Basics)", section on 'Treatment'.)

Iodine — The recommended intake for iodine during lactation is 290 mcg/day. If you live in a country where table salt is iodized (as it is in the United States), some of this requirement will come from your regular diet. However, to meet the full requirement, you should use iodized salt and take a daily multivitamin-mineral supplement or prenatal supplement every day containing 150 mcg of iodine in the form of potassium iodide, as recommended by the American Thyroid Association and the AAP.

The primary risk factors for iodine deficiency are a diet without iodized salt or dairy products. Dietary iodine deficiency may also be worsened by smoking, iron deficiency, and frequent consumption of foods that interfere with the production of thyroid hormones, including brussels sprouts, kale, cabbage, cauliflower, and broccoli. If your diet is very low in iodine, this might cause your baby to have problems with growth, brain development, and thyroid function.

Fish — The recommended intake of omega-3 fatty acids during lactation is 200 to 300 mg daily. You can meet this need with one to two servings of fish per week. You should choose fish that are low in mercury, such as cod, haddock, salmon, or canned light tuna. You should avoid fish with high levels of mercury, such as shark, swordfish, king mackerel, or tilefish. Advice about the preferred types of fish is available from the US Food and Drug Administration.

SAFETY OF MEDICATIONS AND OTHER SUBSTANCES DURING BREASTFEEDING

Medications — Many medications are safe to take while you are lactating. However, there are exceptions. For this reason, it is best to consult with your health care provider, lactation consultant, or pharmacist if you have any questions about whether a particular medicine, herb, supplement, or other product is safe for your baby while you are breastfeeding.

Reliable sources of information about medications during lactation are:

LactMed database (www.ncbi.nlm.nih.gov/books/NBK501922), maintained by the National Library of Medicine

Mother to Baby (www.mothertobaby.org)

List of common medications and other materials from the Infant Risk Center (www.infantrisk.com), from Texas Tech University

Other sources of information about medication safety may not be reliable.

Medications that might affect milk production – Some medications are safe but can potentially affect the amount of milk you produce. For example, combined estrogen/progesterone birth control pills may decrease the amount of milk your body produces, but the effect varies among individuals. In some cases, it may be best to avoid this type of birth control pill. Progesterone-only birth control pills, intrauterine devices (IUDs), and injections are less likely to affect milk supply. Copper IUDs provide long-acting, reversible contraception without any hormones and may be preferable for those who are breastfeeding and want long-term birth control. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

Over-the-counter decongestants that contain pseudoephedrine (sample brand name: Sudafed) can also decrease milk supply.

Medications and drugs to avoid – A few medications are known to be harmful to babies and should be avoided during breastfeeding, if possible. If you're not sure about whether a medication is safe to take while breastfeeding, it's best to ask your health care provider or pharmacist directly. In some cases, they might suggest a safer alternative or monitor your baby for possible side effects.

Illegal drugs such as amphetamines, cocaine, phencyclidine (PCP), and heroin are not safe for you or your baby; people who use these drugs are advised to not breastfeed.

Cannabis — While cannabis (marijuana) is legal in some places, there are limited data on its effects in babies; for this reason, experts advise people who are breastfeeding to avoid all cannabis products (including smoking, vaping, or in edibles).

Alcohol — When you consume alcohol, a small percentage of alcohol is transferred into your breast milk; however, when the alcohol is cleared from the bloodstream, it is also cleared from the milk. The amount of alcohol considered to be "safe" while breastfeeding is controversial. A number of factors affect how much alcohol is transferred to breast milk and how much the baby absorbs.

For an average-weight female, it takes approximately two hours for a single serving of alcohol to clear completely from the body. One serving of alcohol means 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor. To completely avoid any alcohol being transferred to your baby, experts recommend waiting approximately two hours after consuming a single serving of alcohol to breastfeed. Once you have waited two hours, you can breastfeed your baby (it is not necessary to pump and discard your milk). If you drink more than this amount, it is safest to refrain from breastfeeding for an additional two hours for each serving of alcohol.

Caffeine — Most people can drink a moderate amount of caffeine while breastfeeding without it affecting their baby. Experts define a moderate intake of caffeine as two to three cups of a caffeinated beverage (eg, coffee) per day. However, some young babies are sensitive to caffeine and become irritable or have difficulty sleeping, even with small amounts of caffeine. A baby's sensitivity to caffeine usually lessens over time because babies clear caffeine from their system more quickly as they get older (eg, after three to five months of age). If you notice that your baby seems cranky or has trouble sleeping when you consume caffeine, you can try cutting back to see if that makes a difference.

Tobacco — Babies of parents who smoke have an increased risk of a number of conditions, including asthma, pneumonia, ear infections, bronchitis, and sudden infant death syndrome (SIDS), among others. Smoking can also reduce your milk supply. These health risks are caused by the mother's smoking during pregnancy and also by exposing the baby to secondhand smoke after birth.

If you use e-cigarettes (vape), be aware that most vaping devices and liquids contain nicotine (the addictive drug found in tobacco products). Even though e-cigarettes don't generate tobacco smoke, this does not mean they are harmless. Nicotine enters the breast milk. The exact effects of this nicotine exposure on a baby are not known, but some studies have shown that nicotine in breast milk can disturb a baby's sleep and cause changes in heart rate and blood pressure. Vaping nicotine might also decrease your milk production.

You can decrease the risks to your baby by avoiding smoking and vaping in your home or car, either by cutting back on how much you smoke or by quitting. However, for people who are unable to quit, breastfeeding is still more beneficial than formula feeding. If you smoke and want to quit, your health care provider can help. (See "Patient education: Quitting smoking (Beyond the Basics)".)

FINDING A LACTATION CONSULTANT OR OTHER SUPPORT — Resources for finding a lactation consultant, peer support (online or in-person), and other types of support are listed in the table (table 4).

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Health and nutrition during breastfeeding (The Basics)
Patient education: Nutrition before and during pregnancy (The Basics)
Patient education: Breastfeeding (The Basics)
Patient education: Common breastfeeding problems (The Basics)
Patient education: Vitamin B12 deficiency and folate deficiency (The Basics)
Patient education: Vitamin supplements (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Diet and health (Beyond the Basics)
Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Breastfeeding guide (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Pumping breast milk (Beyond the Basics)
Patient education: Calcium and vitamin D for bone health (Beyond the Basics)
Patient education: Anemia caused by low iron in adults (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Breastfeeding: Parental education and support
Common problems of breastfeeding and weaning
Maternal nutrition during lactation
Nutrition in pregnancy: Dietary requirements and supplements
The impact of breastfeeding on the development of allergic disease
Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding
Treatment and prevention of Listeria monocytogenes infection
Prevention of HIV transmission during breastfeeding in resource-limited settings

Websites — The following organizations also provide reliable health information:

National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

Centers for Disease Control and Prevention

(www.cdc.gov/breastfeeding)

American Academy of Pediatrics

(www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/default.aspx)

Academy of Breastfeeding Medicine

(www.bfmed.org)

La Leche League International

(www.llli.org)

Office on Women's Health

(www.womenshealth.gov/patient-materials/health-topic/breastfeeding)

LactMed database – For information about which medications are compatible with breastfeeding

(www.ncbi.nlm.nih.gov/books/NBK501922)

Infant Risk Center – Toll-free phone line for information about medications during lactation: 806-352-2519

(www.infantrisk.com)

Mother to Baby – Toll-free phone line for information about medications during lactation: 866-626-6847 (in English and Spanish)

(www.mothertobaby.org)

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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