Maternal Supplemental Nutrition During Breastfeeding and Infant Growth
by Anne Eglash MD, IBCLC, FABM
No matter the country, it is likely that an underweight mother will be told to eat more calories to increase her milk production. The question is whether this is sound advice.
The study for this week took place in India in 2019, where approximately 20% of mothers have a low BMI and 50% have anemia and other micronutrient deficiencies. Many exclusively breastfed infants in India demonstrate growth faltering, despite the fact that exclusive breastfeeding for the first 6 months is a gold standard for infant nutrition.
The researchers for this study, funded by The Bill and Melinda Gates Foundation, investigated whether supplementing breastfeeding mothers with 600 calories of nutritional snacks would impact growth faltering in their breastfed infants.
The study enrolled 816 mother-infant dyads within the first week postpartum, and randomized them to either the intervention or control group. The mothers in the intervention group were provided 600 kcal snacks daily with 25-30% of calories from fat and 13% from proteins. They were also given vitamin tablets that provided 80-100% of the RDA for most vitamins and minerals. The control group received the same care but except for no nutritional or vitamin supplementation.
Both groups of dyads were visited monthly, and were counseled on exclusive breastfeeding, infant-care practices and maternal nutrition.
At 6 months postpartum the researchers measured infant weight and length, exclusive breastfeeding rates at 1,3, and 5 months of age, maternal and infant hemoglobin, and the maternal mid-upper-arm circumference.
They found that the rate of infant stunting and wasting was no different between the 2 groups. In both groups approximately 15% showed insufficient height growth (stunting), and 9.4-12.1% demonstrated insufficient weight gain (wasting).
What else? Check the question!
- The mothers who received the nutritional snacks/vitamins had a stable body mass index (BMI) during the first 6 months postpartum.
- The mothers who received the nutritional snacks/vitamins exclusively breastfed longer than the control group.
- The mothers who did not receive nutritional snacks/vitamins had a drop in their BMI during the first 6 months postpartum.
- At 6 months postpartum, the mothers who received the nutritional snacks/vitamins were less likely to be anemic than the control group.
- At 6 months postpartum the infants whose mothers received the nutritional snacks/vitamins were less likely to be anemic compared to the control group.
See the Answer
In lower-middle-income settings, growth faltering in the first 6 mo of life occurs despite exclusive breastfeeding.
The aim was to test the efficacy of an approach to improve the dietary adequacy of mothers during lactation and thus improve the growth of their infants.
Eligible mother–infant dyads (infants ≤7 d of age) were randomly assigned to either intervention or control groups. Mothers in the intervention group received snacks that were to be consumed daily, which provided 600 kcal of energy—with 25–30% of energy derived from fats (150–180 kcal) and 13% of energy from protein (80 kcal). Micronutrients were supplemented as daily tablets. We provided counseling on breastfeeding and infant-care practices to mothers in both groups. The primary outcome was attained infant length-for-age z scores (LAZ) at 6 mo of age. Secondary outcomes included exclusive breastfeeding proportion reported by the mother, maternal BMI and midupper arm circumference (MUAC), hemoglobin concentrations in mothers and infants, and the proportion of anemic infants at 6 mo of age.
We enrolled 816 mother–infant dyads. The intervention did not achieve a significant effect on LAZ at 6 mo (adjusted mean difference: 0.09; 95% CI: −0.03, 0.20). Exclusive breastfeeding at 5 mo was higher (45.1% vs. 34.5%; RR: 1.31; 95% CI: 1.04, 1.64) in the intervention group compared with the controls. There were no significant effects on mean hemoglobin concentration or the proportion of anemic infants at 6 mo of age compared with the control group. We noted significant effects on maternal nutritional status (BMI, MUAC, hemoglobin concentration, and proportion anemic).
Postnatal supplementation of 600 kcal energy, 20 g protein, and multiple micronutrients daily to lactating mothers did not affect infant LAZ at age 6 mo. Such supplementation may improve maternal nutritional status.
In this study, the infants of the mothers who received nutritional supplementation did not have a lower risk of stunting or wasting, nor did they have a lower risk of anemia at 6 months. The supplemented mothers demonstrated improved nutritional status, with less postpartum weight loss, less anemia, and higher measurements of the mid-upper-arm circumference.
The authors state that previous studies have not shown conclusively that nutritional supplementation of breastfeeding mothers improves breastmilk volume, composition such as protein concentration, or infant growth. There is stronger evidence that nutritional supplementation of pregnant mothers improves birth height.
Vitamin and iron supplementation will only increase certain nutrients in breastmilk, such as B vitamins, iodine, selenium, A, D, E, and K. Other nutrients in breastmilk such as iron, zinc, phosphorus, and magnesium are not altered by the maternal diet. Therefore, it makes sense that maternal iron supplementation did not reduce the risk of anemia among infants.
The mothers who were given nutritional supplementation had longer periods of exclusive breastfeeding. It is unclear why- the authors suggested that they may have felt more confident about the ability to breastfeed without supplementation.
Although each group was followed closely postpartum for nutritional and lactation support, there was a high rate of insufficient growth among the breastfed infants in both groups. The authors did not address whether breastfeeding complications were managed by knowledgeable professionals, such as insufficient milk transfer (for whatever reason), insufficient glandular tissue, nipple pain, tongue tie, etc.