Hi everyone, welcome to the LactFact weekly podcast, which highlights recent, clinically relevant research, policy statements, and protocols that you, as a practicing lactation professional, should know about. I am your host, Dr Anne Eglash. I am a board-certified family physician and breastfeeding and lactation medicine specialist at the University of Wisconsin School of Medicine and Public Health.

This podcast is written and produced by the nonprofit organization IABLE, which is the Institute for the Advancement of Breastfeeding and Lactation Education. There are no commercial funders for this podcast series.

Today’s LactFact comes from the following article entitled:
International expert consensus on micronutrient supplement use during the early life course
First author- Irene Cetin
Published – BMC Pregnancy and Childbirth 2025 25:44

For background

This study used a method called the modified Delphi process to find out what experts recommend about nutrition and supplements during preconception, pregnancy and lactation.

First, I want to explain what a modified Delphi process is. First, the authors established a steering committee of 8 experts in the field of perinatal nutrition. This committee performed a literature review on maternal nutrition during preconception, pregnancy and lactation. Then the steering committee developed their first survey based on that literature review, which was sent to a panel of 35 nutrition experts. The results of this survey were used to develop a second survey with consensus statements, which went to 32 expert panelists. The goal was to identify where the panelists reached consensus on important topics related to maternal nutrition. Consensus was defined as 75% in agreement of the statement.

I am going to cut to the chase, and share what the panelists agreed on and therefore recommend:

1. HCPs have an important role in providing nutrition and supplement advice from preconception thru lactation.

2. Following the Mediterranean diet because it is rich in antioxidants, vitamins, minerals, polyphenols and fiber. Adherence to the Mediterranean diet during pregnancy has been shown to reduce the risk of gestational DM and gestational weight gain.

3. They recommend supplementation with vit D, folic acid, iodine and iron in the preconception period. This is based on evidence that folic acid prevents neural tube defects such as spina bifida. In addition, iodine deficiency has a negative effect on brain maturation and overall development, and there is widespread iodine deficiency worldwide. Iron supplementation in the preconception period helps to reduce the risk of iron deficiency during pregnancy, which can be associated with significant maternal and infant morbidities.

4. In the first and second trimesters, they recommend supplementation with vit D, folic acid, iodine, iron and DHA. Folic acid in the first several weeks after conception benefits neurocognitive development.

5. In the third trimester, supplementation with vit D, iodine, iron and DHA. They no longer recommend folic acid at that point because it has unclear benefit.

6. Postpartum/lactation- supplement with vit D, iron, DHA, calcium. I will talk about these later.

7. The panelists felt that the evidence to supplement with choline, selenium, vits B1, B2, B6 and K is somewhat to very weak.

8. There is a need to tailor dietary supplementation use according to a person’s lifestyle, such as B12 for vegans

I have a few comments on this study.

First, about calcium- The panelists did not agree on the need for calcium during pregnancy, even though there is increased maternal absorption of calcium during pregnancy to help with maternal and fetal skeletal support. This was probably based on the assumption that women tend to get enough calcium in their diet, especially in countries that eat abundant dairy.

Instead, the panelists had high consensus that calcium supplementation is needed during lactation. However, we have good evidence that calcium supplementation does not have an impact on bone loss during lactation, and if anything, low bone density during pregnancy is a set up for greater bone loss in the first 6 months postpartum. It makes more sense to me for women to take calcium during pregnancy. The CDC and the IOM do not recommend more than 1000mg of calcium during pregnancy and lactation, which is the same recommendation for all women ages 19-50.

A second comment is about iron supplementation. During pregnancy, the IOM’s recommended daily requirement for iron is 27mg, and the average daily intake is about 14.7mg a day. So, it makes sense for pregnant women to take iron.

However, during lactation the amount of iron needed is only 9mg a day, which can easily be achieved by many dietarily. It would make sense to supplement women who are low in iron due to poor dietary intake, or previous iron loses from illness, menstruation or childbirth. I don’t see a reason to have every lactating woman take extra iron.

My last comment is that I appreciate their recommendation to customize nutritional supplementation for the individual. There are several issues to consider regarding an individual’s needs for supplements. Individuals may need certain supplements based on their chronic medications, food allergies, dietary preferences, health habits, culture, geographic region, and/or underlying chronic illnesses. In addition, women who are breastfeeding during pregnancy need special dietary counseling. It would make sense that every woman have a nutritional assessment during preconception and/or during pregnancy and lactation to optimize their health for themselves and their offspring.

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I will be back with another LactFact in 2-4 weeks.