clinical practice
Vitamin supplementation and
nutrition during pregnancy
and breastfeeding
T
he developing baby in the womb is
completely dependent on its mother for
its nutrient supply, so the quality of the
maternal diet is extremely important. During
pregnancy, increased intake is required of several
nutrients, such as vitamins A, B1, B2, C and D and
folate (Table 1). Women’s absorption of certain
nutrients increases during pregnancy, which can
help achieve adequate nutrient levels (Department
of Health (DH), 1991). Despite this, the dietary
intake and/or stores of key nutrients (e.g.
vitamin D) are often found to be low in pregnant
women (McAree et al, 2013). Supplements of folic
acid and vitamin D are recommended around
pregnancy, as diet alone is unlikely to be able to
provide a sufficient supply (DH, 1991).
Women who are breastfeeding require even
more nutrients than when pregnant (DH, 1991).
Increased amounts of the aforementioned
vitamins—along with vitamins B3 and B12—are
required when breastfeeding. Adequate levels of
these vitamins, with the exception of vitamin D,
can be obtained by eating a healthy, varied diet. As
in pregnancy, a daily supplement of vitamin D is
required for breastfeeding women.
Reference nutrient intakes (RNIs) for vitamins
are an estimate of the amount that should meet
the needs of most of the group to which they apply.
They are not minimum targets. Intakes that fall
below the lower reference nutrient intake (LRNI)
are almost certainly not enough for most people;
this is a useful measure of nutritional inadequacy.
This article discusses key nutrients of
importance during pregnancy and breastfeeding:
folate/folic acid, vitamin D, vitamin A and vitamins
B2 and B12.
Folate/folic acid
Folic acid is the name given to the synthetic form
of the B vitamin know as folate. The RNI of folate
for women aged 19–50 is 200 µg. Folate (or folic
© 2015 MA Healthcare Ltd
acid) is needed to prevent neural tube defects
(NTDs) in babies. A baby’s central nervous system
(brain and spinal cord) normally develops first as a
flat sheet of cells (the neural plate) which rolls up
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Abstract
A healthy diet around pregnancy and breastfeeding, which provides
adequate nutrients for the mother and her developing baby, is important
to ensure optimal health for both. Suboptimal nutrient intakes—or
intakes that are too high—can have a detrimental impact on the mother
and her infant in both the short and long term. Even with a healthy
diet, supplementation of some vitamins is recommended to meet
requirements. This article discusses key vitamins required around the
time of pregnancy and during breastfeeding—folate and vitamins A, B
and D—exploring how adequate intake can be ensured.
Keywords: Diet, Pregnancy, Breastfeeding, Nutrition, Vitamins
(the neural tube) in weeks 3–4 of pregnancy and
closes to form the central nervous system. NTDs,
such as spina bifida, may result when the tube does
not close properly. The neural tube forms in the
early weeks, before many women realise they are
pregnant. Since the early 1990s, it was evident that
consumption of folic acid (400 µg per day) around
the time of conception could reduce the risk of
NTDs in babies (Medical Research Council, 1991).
The UK government advises women who
may become pregnant to take a daily folic acid
supplement of 400 µg, continuing up to the
12th week of pregnancy, and to consume foods
providing folate/folic acid in the diet. Such foods
include green salads, peas, broccoli, Brussels
sprouts, cabbage, cauliflower, parsnips, spinach,
tomatoes, oranges, chickpeas, wholemeal bread
and fortified breakfast cereals.
The additional requirement for folate
(the form of the vitamin found naturally in
foods) throughout pregnancy (+100 µg) and
breastfeeding (+60 µg) can be provided by a
diet containing folate-rich foods. As significant
amounts of folate cannot be stored in the body,
a daily dietary supply is important. Folate is Laura Wyness
one of the nutrients commonly found to be low Senior Research Fellow
in the diets of breastfeeding women (Lennox Queen Margaret
et al, 2013). The current average folate intake University
among all women aged 19–64 years is 228 µg Edinburgh
(Bates et al, 2014), which is just above the
695
 clinical practice

Table 1. Summary of vitamins of particular significance during pregnancy and breastfeeding

Nutrient Reference nutrient intake (RNI) Current picture Practical messages Dietary sources
among women
Women Pregnant Breastfeeding
aged women women
19–50
Vitamin A 600 µg +100 µg +350 µg 5% of women Liver is a particularly rich Cheese, butter,
(retinol) aged 19–64 have source of vitamin A, but margarine,
vitamin A intake too much vitamin A can reduced-fat spreads.
below the LRNI; harm the unborn baby. Carrots, dark-green
14% of adolescent Liver and liver products leafy vegetables and
girls (aged 11–18) should not be eaten more orange-coloured fruits
have intakes below than once a week, and provide beta-carotene,
the LRNI1 should be avoided by which the body can
pregnant women2 convert to vitamin A
Vitamin B1 0.8 mg +0.1 mg +0.2 mg Current average Vitamin B1 cannot be Wholegrains, nuts,
(thiamin) (last daily intake among stored in the body, so a meat (especially pork),
trimester adult women aged daily intake is required fruit, vegetables,
only) 19–64 is 1.28 mg1 fortified breakfast
cereals
Vitamin B2 1.1 mg +0.3 mg +0.5 mg/day Around 12% of Many women get most Milk, eggs, fortified
(riboflavin) women aged 19–64 of their vitamin B2 breakfast cereal,
have average daily from animal sources, legumes (peas,
vitamin B2 intakes particularly dairy foods, beans, and lentils),
below the LRNI3 so if they avoid these mushrooms, green
foods it is important that vegetables, almonds
they include non-animal
sources of vitamin B2
Vitamin B3 13 mg No +2 mg Current average Vitamin B3 can be Meat, wheat and maize
(niacin) increase daily intake among synthesised from the flour, eggs, dairy
adult women aged essential amino acid products, yeast
19–64 is 31.6 mg1 tryptophan to meet daily
requirements. Dietary
intake is only necessary
when tryptophan
metabolism is disturbed,
or intake is inadequate
Vitamin B12 1.5 µg No +0.5 µg Current average Vegan diets, and some Milk, eggs, fortified
(cobalamin) increase daily intake among vegetarian diets that breakfast cereals,
adult women aged contain only small legumes (e.g. peas,
19–64 is 4.6 μg1 amounts of dairy products beans, and lentils),
and eggs, are likely to be mushrooms, green
lacking in vitamin B12 vegetables
LRNI–lower reference nutrient intake
1
Bates et al, 2014; 2NHS Choices, 2015a; 3Henderson et al, 2003

non-pregnant RNI of folate. Evidence suggests
that folate levels in breast milk are maintained
at the expense of maternal folate reserves in the
liver and circulating round the body (Hausner
et al, 2008). While this protects the infant, the
nutrient status of the mother and the impact on
Women who have already experienced an
NTD-affected pregnancy are advised to take a 5 mg
folic acid supplement daily (Scientific Advisory
Committee on Nutrition (SACN), 2013) and it
has been suggested that obese women should
also take a 5 mg dose of folic acid daily from
© 2015 MA Healthcare Ltd

subsequent pregnancies would be of concern. before pregnancy until the first trimester (Centre
Breastfeeding women should consume plenty of for Maternal and Child Enquiries (CMACE) and
foods containing folate and folic acid to ensure Royal College of Obstetricians and Gynaecologists
adequate levels are maintained. (RCOG), 2010). This is to help minimise the risk

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 clinical practice

Table 1 continued. Summary of vitamins of particular significance during pregnancy and breastfeeding
Nutrient Reference nutrient intake (RNI) Current picture Practical messages Dietary sources
among women
Women Pregnant Breastfeeding
aged women women
19–50
Folate* 200 µg +100 µg +60 µg Average intake Evidence suggests folate Green leafy vegetables,
among UK women levels in breast milk peas, potatoes, oranges,
aged 19–24 is are maintained at the melon, bananas, beans,
248 µg/day, and for expense of maternal wholegrain products,
women aged 25–34 folate reserves, so nuts, fortified breakfast
is 249 µg/day3. it is important for cereals
Folate is often found breastfeeding women to
to be low in the diet include plenty of foods
of breastfeeding containing folate/folic
women4 acid to maintain supplies
Vitamin C 40 mg +10 mg +30 mg Current average During pregnancy there Fresh fruit (especially
(ascorbic (last dietary intake is a moderate extra drain citrus fruits and berries),
acid) trimester among women aged on the mother’s stores, green vegetables,
only) 19–64 is 81.6 mg1 especially in the final peppers, tomatoes,
trimester. The increased potatoes (especially
RNI ensures maternal new potatoes)
stores are maintained
and breast milk levels
are adequate
Vitamin D No RNI +10 µg +10 µg Current average The main source of Oily fish, eggs, fortified
dietary intake vitamin D is through foods including breakfast
among women aged the action of sunlight cereals, some fortified
19–64 is 2.6 μg1 on the skin. About dairy products and
10–15 minutes of skin reduced-fat spreads
exposure to the sun is
enough for most lighter-
skinned people to obtain
adequate vitamin D2
LRNI–lower reference nutrient intake
*A folic acid supplement of 400 μg/day should be taken before pregnancy and for the first 12 weeks of pregnancy. Larger supplements are required by
women who have already had a neural tube defect-affected pregnancy, and possibly by obese women
1
Bates et al, 2014; 2NHS Choices, 2015a; 3Henderson et al, 2003; 4Lennox et al, 2013

of NTD-affected pregnancies, which are more Vitamin D

prevalent among women with a body mass index
(BMI) of >30 (CMACE and RCOG, 2010). Women
with pre-existing diabetes also require 5 mg folic
acid (Kennedy and Koren, 2012).
Although awareness of the need to take folic
acid appears to be high, compliance with this
recommendation is not necessarily reflected in
practice. In a study in Northern Ireland, 84% of the
296 women reported taking folic acid supplements
in the first trimester, but only 19% had started before
conception (McNulty et al, 2011). As around half of
all pregnancies in the UK are unplanned (SACN,
© 2015 MA Healthcare Ltd
Vitamin D helps the body absorb calcium from the
diet, which is important for healthy bones. There
is also evidence that vitamin D may help protect
against diabetes, cardiovascular disease and some
cancers, as well as optimising immune function
(Buttriss et al, 2013). During pregnancy, vitamin D
is important for the development of the baby’s
bones and teeth. The main source of vitamin D
is through the action of sunlight on the skin
during the summer months. Achieving adequate
vitamin D levels is, therefore, more challenging
in the winter months and for women who cover

2013), health professionals such as GPs, nurses and up their skin when outdoors, along with women
pharmacists have a key role in raising awareness of who have darker skin, such as those of African,
the importance of folic acid in preventing NTDs Afro-Caribbean or South Asian origin. Also at
among women of childbearing age. particular risk of low vitamin D status are those

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 clinical practice
ISTOCK PHOTO
who avoid animal foods or who have a very poor
diet (Crawley, 2014).
There are few dietary sources of vitamin D,
but oily fish—including salmon, mackerel,
trout, anchovies and sardines—is a good source
and eating it once a week can make a useful
contribution to vitamin D intake. Although oily
fish is the richest food source, providing around
3–8 μg of vitamin D per 100 g, few people eat oily
fish (Bates et al, 2012). Some types of fish, such as
shark, swordfish and marlin, should be avoided
during pregnancy, and intake of tuna should be
limited to no more than two tuna steaks a week
or four medium-size cans of tuna a week, to avoid
high intakes of mercury and other contaminants
(NHS Choices, 2015b). Alternative dietary sources
of vitamin D include eggs (a boiled egg provides
3.2 µg) and some fortified breakfast cereals (levels
can vary from 1.5–8.5 µg/100 g) (Williamson and
Wyness, 2013). Spreading a slice of bread with
fortified margarine or spread provides 0.6 μg, and
100 g of lean beef provides 0.7 μg of vitamin D.
Poor maternal vitamin D status will have an
impact on that of the infant and his or her
long-term bone health (British Nutrition
Foundation, 2013). Therefore, a daily supplement
of 10 μg of vitamin D is recommended for all
women throughout pregnancy and breastfeeding.
Low vitamin D status and a lack of awareness
of the importance of a daily 10 µg supplement of
vitamin D during pregnancy and breastfeeding is
widespread across the UK population, particularly
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among young Asian and African-Caribbean
women. In a study of UK pregnant women from
minority ethnic groups, more than 50% had a low
vitamin D status (Datta et al, 2002). A re-emergence
of rickets has been seen in some population groups
in the UK, predominantly in people of African-
Carribean and South Asian origin (Lanham-New
et al, 2011). Some women can obtain free vitamin
supplements via the Government’s Healthy Start
scheme (Gov.uk, 2015).
Many women in the UK have low vitamin D
blood levels, especially in winter and early
spring. Serum/plasma 25-hydroxyvitamin D
(25(OH)D) concentrations reflect the availability
of vitamin D in the body from both dietary and
endogenous sources (i.e. the action on sunlight on
skin). A serum/plasma 25(OH)D concentration
of below 25 nmol/L is currently used to indicate
low vitamin D concentrations (DH, 1991). A
cohort study of pregnant women in north-west
London (n=346) (McAree et al, 2013) reported
that the proportion with a plasma 25(OH)D
concentration below 25 nmol/L was 49% in winter
and 29% in summer. In a study by Haggarty et al
(2013) that included pregnant women (n=1205) in
Aberdeen, Scotland, the percentage with plasma
25(OH)D concentration below 25 nmol/L was
76% in winter and 25% in summer. Women with
darker skin or who conceal most of their skin, or
those who are housebound, are most at risk of
low vitamin D status. Obese women are likely to
be at increased risk of vitamin D deficiency, as
pre-pregnancy weight is inversely associated with
a lower serum vitamin D concentration (British
Nutrition Foundation, 2013). A letter from the UK
Chief Medical Officers to health professionals
was issued in February 2012 to raise awareness
of the risk of vitamin D deficiency among at-risk
groups (Davies et al, 2012). Many women in the
UK have a low vitamin D status which, if severe,
puts them at risk of osteomalacia, the adult form
of rickets (DH, 1991).
Vitamin A
Vitamin A is essential for normal structure and
function of skin. It is also vital for vision, growth
and a healthy immune system. Vitamin A can be
obtained in two forms: preformed retinol found
in animal-derived foods, and carotenoids, which
are mainly plant-derived (beta-carotene being the
most abundant carotenoid), some of which can be
converted to retinol in the body. For this reason,
© 2015 MA Healthcare Ltd
amounts of vitamin A are measured in retinol
equivalents. One retinol equivalent is equal to 1 µg
of retinol, or 6 µg of beta-carotene.
The average daily intake of vitamin A among
British Journal of Midwifery • October 2015 • Vol 23, No 10

women aged 19–64 is 944 μg, with around 1 in 20
(5%) adult women having intakes below the LRNI,
indicating this intake is inadequate (DH, 1991).
Pregnant women require an additional 100 µg/day
and breastfeeding women require an additional
350 µg/day of vitamin A (on top of the 600 μg per
day required by adult women) (DH, 1991). Most
pregnant women in the UK have a vitamin A
intake in excess of the RNI, and therefore only a
small number are likely to need supplementary
vitamin A during pregnancy (DH, 1991). Large
amounts of this fat-soluble vitamin can harm the
unborn baby, causing malformations. Some types
of animal products, such as liver, contain high
levels of vitamin A and should be avoided. Intakes
of retinol equivalents greater than 3000 µg/day are
considered potentially dangerous in pregnancy.
This level of intake is most likely to result from
supplements, including the use of fish oils. For
example, a cod liver oil capsule containing 1000 mg
(1 g) of cod liver oil is likely to contain about 800 µg
of retinol equivalents. Therefore, a teaspoon of cod
liver oil (5 g) will exceed the upper recommended
level of 3000 µg (Crawley, 2014).
Sources of vitamin A include cheese, butter,
margarine and reduced-fat spreads, to which
vitamin A is often voluntarily added (British
Nutrition Foundation, 2013). Carotenoids such as
beta-carotene can be converted to vitamin A in
the body. Dietary sources of carotenoids include
dark green leafy vegetables, orange-coloured fruits
(such as mangoes and apricots) and vegetables
such as sweet potatoes, carrots and tomatoes
(Crawley, 2014).
B vitamins
Vitamin B2 helps to release energy from food
and maintain the health of mucous membranes,
such as those in the mouth and intestines. Adult
women require 1.1 mg/day of vitamin B2, but
pregnant women need an additional 0.3 mg/day
and breastfeeding women need an extra 0.5 mg/
day (DH, 1991). This extra amount of vitamin B2
can be found in a small bowl of fortified breakfast
cereal. Many women get most of their vitamin B2
from animal sources, especially dairy foods such as
milk, cheese and yoghurt. Around 12% of women
aged 19–64 have average daily vitamin B2 intakes
below the LRNI (Bates et al, 2014).
Vitamin B12 helps make red blood cells and
keeps the nervous system healthy. The RNI during
pregnancy remains at the same level as that for
© 2015 MA Healthcare Ltd
non-pregnant women (1.5 μg/day). However,
breastfeeding women need an additional 0.5 μg/
day of vitamin B12 (DH, 1991). Vitamin B12 is
found in almost all foods of animal origin, such as
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clinical practice
Key points
ll Several vitamins are required before and during pregnancy and while
breastfeeding to ensure good health in both the mother and baby
ll Health professionals have a key role in raising awareness among women
of childbearing age of the importance on folic acid in preventing neural
tube defects in infants
ll The vitamin D status of newborn babies is dependent on maternal
vitamin D status, and many women in the UK currently have low
vitamin D blood levels. A daily 10 μg vitamin D supplement should be
taken during pregnancy and breastfeeding
ll Some women, such as those on a vegan diet, will require additional
vitamin supplementation
ll Some pregnant women may be entitled to receive free vitamin
supplements via the Government’s Healthy Start scheme
meat, fish, poultry, eggs, milk and dairy products,
as well as yeast extract and fortified breakfast
cereals. The current average intake of vitamin B12
among adult women aged 19–64 is 4.6 μg/day
(Bates et al, 2014). However, vegetarian diets that
contain only small amounts of dairy products
and eggs, and particularly vegan diets where no
animal products are consumed, are likely to be
lacking in vitamin B12 (and may be also be low in
calcium, vitamin B2, iron and vitamin D) (Lennox
et al, 2013). Women with vegan diets may require
vitamin B12 supplementation.
Suitable vitamin supplements
A daily folic acid supplement is recommended
for women before conception and during the
first 12 weeks of pregnancy, and all pregnant
and breastfeeding women should take a daily
vitamin D supplement. Some women (all
those under 18 and those who receive certain
benefits) may be entitled to receive free vitamin
supplements of folic acid, vitamin D and vitamin C
via the Government’s Healthy Start scheme (www.
healthystart.nhs.uk). No other supplements are
recommended, and some may even be harmful.
General multivitamins that contain vitamin A
(retinol) are unsuitable, as high intakes of this
vitamin in supplement form can be dangerous for
the fetus. Any supplements containing vitamin A,
high-dose multivitamin supplements and fish
liver oil supplements should be avoided. Certain
herbal preparations should also be avoided as
they may not be safe (Crawley, 2014). Taking many
supplements does not improve health, and may
have an adverse impact on health.
Vegan pregnant women may require vitamin B12
supplementation in addition to folic acid and
vitamin D (Crawley, 2014). The Vegan Society
produces a supplement called VEG1—which
699
 clinical practice
ISTOCK PHOTO
contains vitamins B2, B6 and B12, vitamin D, folic
acid, iodine and selenium—specifically for vegan
pregnant women (Vegan Society, 2015).
Resources
Health professionals may direct pregnant women
to the pregnancy and baby guide available
from the NHS Choices website (www.nhs.
uk/Conditions/pregnancy-and-baby/pages/
pregnancy-and-baby-care.aspx). There are also
a variety of resources available from First Steps
Nutrition Trust (www.firststepsnutrition.org)
on topics including eating well in pregnancy
and making the most of Healthy Start. To help
women make positive changes to their health
both before and after pregnancy, the British
Nutrition Foundation has produced a 4-week
planner along with information and practical
advice on healthy eating and physical activity,
which is free to download from its website (www.
nutrition.org.uk/healthyliving).
Conclusion
A healthy, varied diet is important for ensuring
both the mother and her developing baby receive
adequate nutrition. This article has highlighted
key vitamins that are needed during pregnancy
and breastfeeding. Wherever possible, these
should be provided by a good diet. However,
supplements of folic acid (around early pregnancy)
and vitamin D for pregnant and breastfeeding
women are recommended, and vegan pregnant
700
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women may require supplementation of
vitamin B12, among other nutrients. Free vitamin
supplements are available to some women through
the Government’s Healthy Start scheme. Good
nutrition and a healthy lifestyle around the time
of pregnancy and breastfeeding are likely to
benefit the health of both mother and baby—and,
therefore, the health of future generations.  BJM
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