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GET THIS BOOK Meghan Harrison, Rapporteur; Food and Nutrition Board; Health and Medicine
Division; National Academies of Sciences, Engineering, and Medicine
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BOX 7-1
Highlights from the Session 6 Presentations
NOTE: These points were made by the individual workshop speakers identified
above. They are not intended to reflect a consensus among workshop par-
ticipants. The statements have not been endorsed or verified by the National
Academies of Sciences, Engineering, and Medicine.
estimates for selected nutrients, and the Mothers, Infants and Lactation
Quality (MILQ) study.
TABLE 7-1 Summary of Data Available for Setting Adequate Intakes for
Infants and Lactation for Select Nutrients
Nutrient Value Used by IOM Data Range/Other Studies
Vitamin B1 0.21 ± 0.4 mg/L Only study,
source unknown
Vitamin B2 0.35 (0.31–0.51) mg/L n = 5, USA Only 1 study with valid
methods
Niacin 1.8 (1.2–2.8) mg/L n = 23 Only 1 study
(UK 16–244 d)
Pantothenic 1.7 mg/d 2 studies Range: 2.2–2.5 mg/L, but
acid (UK, USA) higher values include women
consuming supplements
Vitamin B6 0.13 (0.07–0.18) mg/L n = 6 (USA, Intakes were < RDA
3 wk to 30 mo) mean = 0.24 versus 0.31 if
intake > RDA
Biotin 5 μg/d 3 studies Range: 3.8–7ug/L but different
methods across studies
Vitamin B12 0.42 (0.01–1.47) μg/L n = 9 (Brazil, 0.31 (vegan), 0.34, 0.91
4 d to 3 mo) (supplemented)
Choline 125 mg/d 2 studies 160–200 mg/L
Vitamin C 50 mg/L 8 studies, Range 34–83 mg/L if no
n = 12–200/study supplement
NOTE: d = day; IOM = Institute of Medicine; mg/L = milligrams per liter; μg/d = micrograms
per day; μg/L = micrograms per liter; mo = months; RDA = Recommended Dietary Allowance.
SOURCES: Presented by Lindsey Allen. Adapted from Allen et al., 2018.
the evidence as “an appalling sparsity of data on which to set the recom-
mendations for infants and for lactation.”
Allen’s lab focuses on developing efficient analytical methods for
analyzing breast milk composition, using techniques such as inductively
coupled plasma mass spectrometry and high-performance liquid chroma-
tography. She indicated that mass spectrometry has been transformative
and can be used to measure most of the B vitamins. Allen’s team is also
starting to investigate metabolomics. Recent breast milk estimates globally
show median concentrations below the values that were used for the exist-
ing infant AIs for several micronutrients.
Thiamin
The breast milk concentration used to establish the infant AI for
thiamin was 210 μg/L and was derived from a single study. New evidence
from a collection of high-income countries revealed a median thiamin
concentration in breast milk of 125 μg/L. A supplementation trial con-
ducted in Cambodia was able to increase breast milk concentrations from
approximately this level to the concentrations used to establish the infant
AI for thiamin. However, the new estimate of median concentrations is
likely closer to normal and suggests the infant AI for thiamin is higher than
infant needs, said Allen.
Vitamin B6
The prevalence of vitamin B6 deficiency is not well characterized
nationally or internationally. Based on 2014 National Health and Nutri-
tion Examination Survey (NHANES) data, 24 percent of U.S. women who
do not use supplements have low serum pyridoxal phosphate; serum and
breast milk concentrations are correlated, added Allen. In several countries,
particularly low-income countries, breast milk vitamin B6 concentrations
are below 0.13 mg/L, the value used to establish the infant AIs. One small
study, conducted in lactating women from Davis, California, who were
not taking supplements during lactaction, found an average vitamin B6
concentrations of 0.3 mg/L. Allen suggested that this higher concentration
could possibly be attributable to high vitamin B6 content of some prenatal
vitamins.
Iodine
“I would say of all the nutrients, iodine is the most sensitive to maternal
intake,” stated Allen. She noted that despite salt fortification programs, low
concentrations of iodine in breast milk are common. Across longitudinal
studies iodine concentrations in breast milk are variable, but generally there
is a marked decrease in iodine content during the first month of lactation.
The only longitudinal study assessing the iodine content of breast milk in the
United States was conducted in 31 Mexican American women and found
concentrations below the values used to establish the iodine AIs for infants.
Breast milk iodine concentrations mirror maternal urinary iodine excretion.
In a systematic review of 57 studies, the concentration of iodine in breast
milk was 13–18 μg/L among women with goiter, whereas women in areas
with effective salt iodization had breast milk iodine concentrations exceeding
90 μg/L.
Different groups have considered improving the iodine status of lactat-
ing women. For instance, the American Pediatric Association and American
Thyroid Association recommend that lactating women supplement with
150 μg/day, and the World Health Organization (WHO) recommends that
lactating women in areas with moderate or severe iodine deficiency supple-
ment their diets with 250 μg/day. Iodine is preferentially lost in breast milk
over urine when status is low during lactation. To that end, it has been
suggested that the iodine content of breast milk may be a better indicator
of iodine status among lactating women (Dold et al., 2017).
Allen noted that older analytical techniques for measuring iodine
concentrations in breast milk are no longer considered valid. The breast
milk iodine concentration, used in the derivation of the iodine AIs for
infants and lactating women, came from a single study from 1984. New
evidence suggests infant needs are lower than previously estimated, mean-
ing the iodine AI for lactating women is likely too high, said Allen. She
continued with the caveat that infants have limited opportunity for iodine
exposure. Weaning infants are at risk of iodine deficiency, particularly
when breast milk iodine content is low, as complementary foods tend to
be low in iodine.
Vitamin B12
A recent systematic review has assessed the state of the evidence on the
vitamin B12 content of breast milk (Dror and Allen, 2018). Allen reported
that 7 of the 26 identified studies used invalid analytical techniques. Vita-
min B12 concentrations vary widely, but they appear to decrease during
early lactation. The vitamin B12 content of breast milk correlated with
maternal intake, along with maternal and infant status.
Vitamin D
Breast milk is a poor source of vitamin D. As such, the American
Academy of Pediatrics recommends 400 IU/day of vitamin D be given to
breastfed infants. A recent study has demonstrated that lactating women
who take a 6,400 IU/day vitamin D supplement can supply infants with
sufficient vitamin D through breast milk (Hollis et al., 2015). Pointing out
that the supplement dose exceeds the vitamin D Tolerable Upper Intake
Level of 4,000 IU/d, Allen indicated that such an intervention may not be
Other Micronutrients
Allen stated that there is no breast milk composition data for several
micronutrients. As an example, she explained that survey data from C anada,
Europe, Ireland, and the United Kingdom found riboflavin depletion in
20–60 percent of adults and commented that there are no estimates for the
United States. Severe riboflavin deficiency has been associated with poor
infant growth and development. Evidence from low-income countries indicate
that breast milk concentrations respond to maternal intake to a greater degree
than many of the other nutrients. Maternal supplementation during lacta-
tion, however, may not be an effective strategy for some nutrients. A study of
exclusively breastfed infants in Malawi found that 2–5 percent of nutrients in
a supplement given to lactating women appears in their breast milk.
MILQ Study
Allen closed her presentation by providing a brief overview of the
MILQ study. The goal of the project is to create human milk reference
values for nutrients during the first 9 months of lactation. The study aims
to recruit 1,000 well-nourished, nonsupplemented women and their infants
from four countries.
noted that the comparative analysis of the existing body of evidence is dif-
ficult because of differences in study design and confounding. She said that
women of lower socioeconomic status are less likely to be reflected in the
data. Finally, she explained that while donor milk banks standardize for
macronutrients, they do not standardize for other breast milk factors, and
she thought further work was needed to preserve the content donor milk.
CARDIA
Gunderson highlighted some of the key study design elements that
sets CARDIA apart from other epidemiological studies that have explored
the relationship between lactation and long-term chronic disease risk. The
study enrolled 2,787 women 18–30 years of age (mean age: 24 years) who
were followed for 30 years. Half of the cohort was black and half was
white. Biochemical data were collected longitudinally beginning from the
preconception period, and assessments were performed years later to col-
lect measures of diabetes and metabolic disease. The study’s data collection
schedule allowed for a greater understanding of the cardiometabolic risk
factors present prior to pregnancy, the changes in the metabolic risk factors,
and other factors that may affect the lactation–disease relationship, includ-
SWIFT
SWIFT, also a prospective cohort study design, enrolled 1,035 women
who had gestational diabetes diagnosed by Carpenter and Coustan cri-
teria (Gunderson et al., 2012). All women underwent a research 2-hour,
75 g oral glucose tolerance test (OGTT) at each of three research visits
from study baseline (6 to 9 weeks postpartum) and annually for up to
2 years later. A fourth in-person research visit will be conducted in 2021
2 Gunderson reported the models controlled for fasting glucose, insulin resistance, family
history of diabetes, physical activity, diet quality, perinatal outcomes, and follow-up changes
in weight.
(Gunderson et al., 2014), but she surmised that other mechanisms could be
driving the observed differences.
To contextualize the importance of the findings from CARDIA and
SWIFT, Gunderson explained that the Diabetes Prevention Program had
found that a 5 kilogram weight loss through a diet and physical activity
intervention reduced the risk of incident diabetes in adults with prediabetes
by 58 percent. Given the similar strength of associations for lactation inten-
sity and duration, she conjectured, “This is a specific lifestyle behavior in a
critical period, the postpartum period, that may actually have very strong
metabolic consequences.” Gunderson cited research evidence attributing an
annual excess of deaths for women later in life to suboptimal breastfeed-
ing. As heart disease is the leading cause of death among U.S. women, and
type 2 diabetes is a risk factor, she concluded that the impact of lactation
on women’s health has been underappreciated.
DISCUSSION
Allen, Demerath, and Gunderson responded to audience questions. In
the discussion, moderated by O’Connor, questions were raised related to
lactational programming, studying breast milk composition, and factors
affecting lactation success.
Lactational Programming
Prefacing that her question related to the application of the concepts of
lactational programming, Leanne Redman from the Pennington Biomedical
Research Center asked if there were existing recommendations related
to nutrition before, during, and after pregnancy to optimize breast milk
composition. Allen explained that there are no WHO recommendations
on supplementation during lactation. She thought that, until functional
deficits in infants are identified, there will remain inadequate interest and
investment in the topic.
A webcast audience member, who referenced a possible U-shaped
relationship between maternal leptin concentrations and offspring obe-
sity, wanted to know if there was an effect modification by BMI status.
Demerath responded that more data are needed to better characterize the
relationships. She noted that most studies do adjust for BMI, but effect
modification could still be a factor.
milk composition, and infant outcomes, given that some randomized con-
trolled trials may not be ethical to conduct. Demerath acknowledged that
only certain types of trials would be considered unethical, such as remov-
ing an essential nutrient from the diet. She suggested that trials promoting
healthy dietary patterns coupled with pregnancy weight management would
be useful. Allen added that she has been involved in several micronutrient
trials in developing countries and said the challenge is identifying and mea-
suring functional outcomes in infants. When asked by a webcast audience
member if it is known whether breast milk that is pumped, as opposed to
consumed directly from the breast, confers the same health benefits for
mother and child, Gunderson responded that SWIFT collected such data,
but it has yet to be analyzed.
Referring to Allen’s presentation on the content of vitamin B12 in
breast milk among vegetarian and vegans, Johanna Dwyer of the National
Institutes of Health’s Office of Dietary Supplements pointed out that there
were observational studies conducted in the 1970s on mothers in Boston
following macrobiotic diets. Allen, who was involved in the study Dwyer
referenced, noted that detrimental effects were found in the infants, but she
said the analytical technique to measure vitamin B12 concentrations used
in those studies is no longer considered valid.