Accepted Manuscript

Breast milk is conditionally perfect

Miriam Erick

PII: S0306-9877(17)30649-7
DOI: https://doi.org/10.1016/j.mehy.2017.12.020
Reference: YMEHY 8757

To appear in: Medical Hypotheses

Received Date: 25 June 2017

Accepted Date: 13 December 2017

Please cite this article as: M. Erick, Breast milk is conditionally perfect, Medical Hypotheses (2017), doi: https://
doi.org/10.1016/j.mehy.2017.12.020

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 Breast milk is conditionally perfect (YMEHY_2017_571)

(c) 2017

Miriam Erick, MS RDN CDE LDN

Department of Nutrition
Brigham and Women’s Hospital,
Boston MA 02115 USA

Abstract

Breast milk is the universal preferred nutrition for the newborn human infant. New mother

have been encouraged to exclusively breastfeed by health care professionals and consumer-

advocacy forums for years, citing “breast milk is the perfect food”. The benefits are numerous

and include psychological, convenience, economical, ecological and nutritionally superior.

Human milk is a composite of nutritional choices of the mother, commencing in the pre-

conceptual era. Events influencing the eventual nutritional profile of breast milk for the

neonate start with pre-conceptual dietary habits through pregnancy and finally to postpartum.

Food choices do affect the nutritional profile of human breast milk.

It is not known who coined the phrase “breast milk is the perfect food” but it is widely

prevalent in the literature. While breast milk is highly nutritive, containing important

immunological and growth factors, scientific investigation reveals a few short-falls. Overall,

human breast milk has been found to be low in certain nutrients in developed countries:

vitamin D, iodine, iron, and vitamin K. Additional nutrient deficiencies have been documented

in resource-poor countries: vitamin A, vitamin B 12, zinc, and vitamin B 1/ thiamin.

1
Given these findings, isn’t it more accurate to describe breast milk as “conditionally perfect”?

Correcting the impression that breast milk is an inherently, automatically comprehensive

enriched product would encourage women who plan to breastfeed an opportunity to

concentrate on dietary improvement to optimizes nutrient benefits ultimately to the neonate.

The more immediate result would improve pre-conceptual nutritional status.

Here, we explore the nutritional status of groups of young women; some of whom will become

pregnant and eventually produce breast milk. We will review the available literature profiling

vitamin, mineral, protein and caloric content of breast milk. We highlight pre-existing

situations needing correction to optimize conception and fetal development.

While alternative forms of infant nutrition carry standard product labels of nutrient adequacy,

this information does not apply universally to all breast milk. Infant formulas are fortified with

various amounts of vitamins, minerals, supplemental protein concentrates, nucleic factors,

omega 3 fatty acids and any important new nutritional finding. Infant formulas are

manufactured to be consistent in composition and are monitored closely for quality. Not true

for human breast milk.

Any nutrient deficiency existing in pregnancy will ultimately be carried forward via lactation. It

is a biological impossibility for a lactating woman to transfer nutrients via breast milk she does

not have!

2
3
Introduction

Breast milk is the universal preferred nutrition for the newborn human infant. New mothers

have been encouraged to exclusively breastfeed by health care professionals and consumer-

advocacy forums for years globally, citing “breast milk is the perfect food”. The benefits are

numerous and include nutritional, psychological, convenient/ready to feed, economical,

ecological and immunological.

Human milk is a composite of nutritional choices of the mother, starting in the pre-conceptual

era. Events that influence the nutritional profile of breast milk for the neonate include pre-

conceptual dietary habits, through pregnancy and finally to postpartum and lactation. Food

choices do affect the nutrient profile of human breast milk.

While alternative forms of infant nutrition carry standard product labels of nutrient adequacy,

this information does not apply universally to all breast milk. Infant formulas are fortified with

various amounts of vitamins, minerals, supplemental protein concentrates, nucleic factors,

omega 3 fatty acids and other relevant factors from current studies. Alternative infant formulas

are consistent in composition and monitored closely to ensure quality. This is not universally

true for human breast milk. (1) (2)

This paper presents findings from the literature regarding the potential compromised

nutritional status of women from various global communities. Some of these women are in

the pre-conceptual stage of life, some are pregnant and some postpartum and breast feeding.

4
Where nutrient deficits exist, the importance for effective nutrition intervention for the

postpartum needs of the new mother is critical. Only when the new mother is adequately

nourished can she provide optimal nourishment via breast milk to the neonate who has a

metabolically active and developing brain.

Hypothesis

It is not known who first coined the phrase “breast milk is the perfect food for the infant” but it

is widely prevalent in the literature. While breast milk is highly nutritive and contains

important immunological and growth factors, scientific investigation reveals a few short-falls.

Overall, human breast milk has been found to be low in certain nutrients in developed

countries: vitamin D, (3) (4 ) iodine (5), iron (6) (7) (8) and vitamin K. (9) (10). Additional

nutrient deficiencies have been documented in resource-poor countries: vitamin A (11) (12),

vitamin B 12 (13), (14), (15), (16), zinc (11), (12), and vitamin B 1/ thiamin. (17 ), (18).

Given these findings, isn’t it more accurate to describe breast milk as “conditionally perfect”?

Correcting the impression that breast milk is an inherently, automatically comprehensive

enriched product would encourage women who plan to breastfeed an opportunity to

concentrate on dietary improvement to optimizes nutrient benefits ultimately to the neonate.

The more immediate action should improve pre-conceptual nutritional status.

5
We explore the nutritional status of groups of young women; some of whom will become

pregnant and eventually produce breast milk. We will review the available literature profiling

vitamin, mineral, protein and caloric content of breast milk.

Expanding on the Barker Hypotheses, maintaining that adult diseases begin in utero we present

examples. What we know is frank iodine deficiency in pregnancy reduces fetal/neonatal IQ,

which is a cognitive injury. We also know that pre-conceptual folic acid deficiency results in

neural tube defect, a physical injury. Our last example is iron; a deficiency in pregnancy

reduces fetal myelin development which is associated with reduced attention span, and also

implicated in small for gestational age (SGA) neonates; resulting in both a cognitive and physical

compromise. What degree of nutritional compromise results in deficit is unknown.

Central to our hypothesis is that there are likely nutrients; vitamins, minerals, protein and fat; in

the human brain, as extrapolated from reference data on nutrients in animal brain used for

food. The data on nutrients in animal brain likely represents the by-product of optimal

nutrition to develop the flesh of animals for consumption. (19) Nutrients in the brain are

conveyed from the dietary intake of the subject. In pregnancy, the maternal intake would be

the vehicle in which nutrients are conveyed to the developing fetal brain. Not all pregnant

women meet nutritional adequacy. (20)

Nutrient deficiencies existing in pregnancy will be carried forward via lactation. It is a biological

impossibility for the lactating woman with any nutrient deficiency to transfer that nutrient to

6
breast milk. The newborn brain develops rapidly and requires optimal substrate to meet

optimization. Nutritional shortfalls in the neonate are not immediately apparent. Remediation,

however, after a defect is discovered may not remedy the insult. The window of opportunity

may have closed.

Life stages of nutritional concern

Table 1 highlights several situations which may present in a woman’s life that can impact her

nutritional status. Column 1 lists potential conditions which need attention pre-conceptually.

Nutrient deficits, pre-existing and if not corrected, will likely continue on their established

orbital paths which will impact optimal fetal development.

Our review of the literature acknowledges sub-optimal nutrition in pre-conceptual women is

not uncommon. Wide-spread folic acid insufficiency, a form of malnourishment, points to only

one example of inadequate nutrient intake which had documented adverse implications for

pregnancy outcome. The action which resulted as a result of this knowledge was a universal

recommendation to take supplemental folic acid at least 3 month prior to conception. (46)

The concept of malnutrition/malnourishment in relatively healthy-appearing persons is a

difficult one, especially in the obese. In the early 1970’s hospital malnutrition was

acknowledged as “the skeleton in the closet” affecting 10-50% of patients. (47)

(48)(49) Malnutrition in pregnancy is also among the unrecognized “skeletons in the closet”.

7
Preconception

Poverty/resource inadequacy affects the majority of developing countries with micronutrient

deficiencies which contribute to significant public health issues, negatively affecting maternal

and infant/child health outcomes. (36). A study of 4,983 rural women of reproductive age in

Vietnam participating in a pre-conceptual micronutrient supplementation trial revealed the

estimated average requirement was 25% for iron, 16% for zinc, 54% for folate, 64% for vitamin

B 12 and 27% for vitamin A. Each of these nutrient shortfalls has repercussions in the

developing embryo.

In more affluence countries, unidentified eating disorders affect pregnancy. Anorexia nervosa,

bulimia nervosa and binge eating disorders have lifetime prevalence estimates of .9%, 1.5%,

and 3.5% among women. It is estimated that only a minority of cases seek treatment. (21) (22)

Restricted food intake restricts nutrient availability.

Bariatric surgery for obesity has many benefits and a few caveats. Adequate oral contraception

after bariatric contraception ensures the woman has had enough time to stabilize weight and

optimize nutritional status. (35) Weight loss alters the hormonal balance between testosterone

and estrogen which increases fertility potential. Becoming pregnancy within a year of weight

loss surgery is not advised due to concerns over nutritional adequacy for fetal development.

Bariatric surgery has the potential to alter oral contraceptive agent (OCA) efficacy. Absorption

of OCA after bariatric surgery can be reduced if intestinal length has been altered. Experts

8
recommend adding a secondary agent such as barrier methods to prevent unintended

pregnancy until adequate nutritional status is achieved.

Non-adherence to nutritional supplementation after bariatric procedures was studied in 92

subjects after six months procedure and compliance found to be 30%. (26) While most of these

study persons were male and fully employed, this observation raises concern for women in the

reproductive years.

Paradoxically even with obesity, micronutrient malnutrition also co-exists. The American

Society for Metabolic and Bariatric Surgery reviewed the prevalence of pre-weight loss surgery

(WLS) micronutrient deficiency as well as post WLS nutrient deficiencies. (25) These findings

are presented in Table 2. Multiple nutrient deficiencies can exist in a single individual.

Pregnancy

Despite various recommendations for nutrient increases for pregnancy, not all women enter

pregnancy nutritionally replete. (23) Recommended Dietary Allowances (RDA’s) for pregnancy

for micronutrients (vitamins and minerals) remain constant throughout the trimesters except

for calories. (50 IOM) Maternal nutritional assessment is not routine hence nutritional

adequacy is different to determine. (43).

Prenatal supplemental vitamin tablets are regularly prescribed, however the compositions of

supplemental nutrients vary widely and none includes protein or energy components. Until

recently some prenatal supplements lack iodine, an essential nutrient. This decision was the

9
result of focus data from women having an adverse reaction to pyleogram (IVP) dye and/or

seafood that they were allergic to iodine.

A 2002 study from Newark, New Jersey Baker et al identified at least 5 sub-clinical nutrient

deficiencies in a population of randomly selected 563 women, all enrolled in the WIC (Women,

Infant and Children) Program. (51) All women were compliant with prenatal supplementation

and assessed by registered dietitians as having adequate diets. Twelve nutrients were

assessed by different trimester: Niacin, thiamin, vitamin A, vitamin B 12, vitamin B 6, folic acid,

biotin, pantothenic acid, riboflavin, vitamin C, carotenes and vitamin E. Eighty three non-

pregnant women, aged 24-36, provided reference values for these nutrients. Details are

provided in Table 3. (51)

Baker’s group concluded an average of 20-30% of pregnant women suffer from a vitamin

deficiency. Potential etiology of maternal decline of nutrients by trimester, speculated by this

author, include increased fetal requirement corresponding to growth and development in the

setting of decreased intake due to reduced maternal gastric space and early satiety, both

prevalent in advanced gestation. Of the 563 women included in this study, 53 neonates were

of low birth weight, less than 1500 grams. While they attempted to correlate low birth weights

as well as parity, gestational age with changes in the deficient nutrients, e.g. niacin, thiamin,

vitamin A, vitamin B 12, they found no statistical correlation using the Wilcoxon’s rank sum test.

Baker’s group theorized perhaps clearer correlations with factors involving pregnancy outcome

10
with hypovitaminemias might have emerged without prenatal supplements. However they felt

it was unethical withhold prenatal supplements. (51)

A recent Canadian study of the prevalence of B 12 deficiency in an unselected group of

pregnant women found 1 in 20 women were biochemically deficient for vitamin B 12 in early

pregnancy. Another study involving pregnant adolescents revealed 50% had suboptimal

vitamin B 12 levels. (52)

Deficiencies in other nutrients, such as iron, vitamin K, folate and calcium can result in both

maternal complications such as severe anemia and fetal complications such as congenital

abnormalities, intrauterine growth restriction (IUGR) and failure to thrive (FTT). (40 Guelinckx).

Vitamin K embryopathy, found in some severe HG cases, affects bone and cartilage

development and can have a wide range of presentations. (53)

Multiple gestations generate additional metabolic demands on maternal stores. Nutritional

recommendations have been provided for twins and triplets. (54) (55). Studies shows higher

rates of preterm infants and small for gestation age (SGA) neonates born to women suffering

from extremely poor nutritional intake due to severe hyperemesis gravidarum (37 ) (38) with

higher rates of learning disorders in these children. There is speculation early nutrient

deficiencies might play a role in the development of autism. (56) (57) A relationship between

diet, neurotransmitters and brain function has been established. (58).

11
An evaluation from the WIC (Women, Infants and Children Supplemental Feeding Program)

demonstrated that with continuation of the prenatal vitamin during lactation, with targeted

nutrition education and vouchers for healthy food, the rate of autism among the children of

participants was reduced. (59)

Bariatric surgery has known consequences in persons poorly compliant with nutritional

protocols. If the non-compliant person is a pregnant woman, nutrient deficits impact the

developing fetus. (40) Compliance to bariatric nutritional protocols and follow up evaluations

are variable and can be associated with insurance issues. (24) Providers who counsel women

pre-conceptually should inquire about changes in memory, mood and skin changes, night

vision, and hair loss along and frequency of bariatric follow up.

Despite compliant, adequate nutrient levels cannot always be achieved. (44) One case report

of a compliant woman to supplementation after a biliopancreatic diversion surgery for obesity

7 years before pregnancy was fund to have severe, maternal hypovitaminosis A during

gestation, manifesting a night blindness. The infant was born with undetectable serum vitamin

A levels, microphthalmia, inferior adherent leukoma and optic nerve hypoplasia. At 9 months

of age, electroretinopathy suggested rod dysfunction in the infant.

Night blindness, due to inadequate vitamin A intake in an impoverished pregnant woman, will

also affect the visual acuity of the fetus and increases risk for infection in the neonate. In

addition sub-optimal zinc intake during pregnancy is associated with SGA infants who also have

12
reduced immune capacity and an increased risk for infection. Data are provided in Tables 4 and

5. (12)

Postpartum

Lactation, the process of producing nutritionally appropriate sustenance with immunological

benefit, is a physiologically and metabolically demanding activity which occurs after the delivery

of an infant.

The informative and detailed summary of nutrient content of human breast milk of well-

nourished women is provided in Table 6 and appears it is constant (Lawrence). However a

review of the literature suggests the nutritional content of human breast milk is not uniform

but dynamic, reflecting maternal dietary intake. (1) (3) (8) (11) (14) (15) (16) (18) (41) (61)

(62) (63) (64) (65) (66) (67) (68) (69)

Breast milk has been assumed to provide 20 kilocalories/ounce. However, a study of breast

milk from lactating mothers of NICU infants, producing milk in excess of their infants’ needs,

showed high variability in nutrient content and an average 17.9 kilocalories/ounce. (70)

Phrynoderma and acquired acrodermatitis enteropathica, both skin lesions, were reported in

two women following Roux-en-Y gastric bypass surgeries. One woman was diagnosed with a

vitamin A deficiency and the second with zinc deficiency. (45) While both women experienced

symptoms during pregnancy, clinicians felt the additional metabolic demands associated with

13
lactation further depleted nutrient stores, worsened lesions which drove women to specialists

for treatment.

Human breast milk has very little iron- 0.4 mg/L. (6) Iron supplementation of exclusively

breast fed infants needs to occur by 4 months if the mother had an uncomplicated healthy

pregnancy as the neonatal stores will be depleted. (6)(7). In study of 68 late preterm infants

born between 32 and 35 weeks of gestation, iron depletion and iron depletion anemia were

present in 38.2% and 30.9% of the infants by 6 weeks post natal life. Early supplementation for

the late preterm infant with a low birth weight (< 1830 g) and a low serum ferritin (< 155 ug/l)

in the absence of infection in the first week of life is needed to avoid iron depletion which may

lead to impaired neurodevelopment. (8)

Vitamin B 12, a key nutrient for neurological development, is low in breast milk of impoverished

women whose diet is low in animal protein, those with un-supplemented vegan diets as well as

some after bariatric procedures with poor compliance to nutritional protocols. (14) (15) (16)

(26) (61)

The vitamin D concentration in breast milk of women taking 400 international units (IU) of

vitamin D per day in pregnancy is relatively low, leading to vitamin D deficiency in breastfed

infants. The vitamin D activity in normal lactating women is known to be in the range of 5 to 80

IU depending method of assay. Supplementation with vitamin D to the nursing infant has been

endorsed by the American Academy of Pediatricians (AAP) and the Institute of Medicine (IOM).

14
Compliance to this practice is poor, ranging from 2-19%. (3) In a US study supplementing

nursing mothers with 400, 2400 or 6400 IU vitamin D3 daily for 6 months showed

supplementation with 6400 IU/day safely supplied breast milk with adequate vitamin D to meet

infant requirements and offered an alternative strategy to direct infant supplementation. (3)

Breast milk is low in vitamin K. (7) (10) Infants who are exclusively breastfed and who do not

receive intramuscular (IM) vitamin K at birth are at risk for hemorrhagic disease (HDN) of the

newborn. In a case report, a four week old infant, exclusively breastfed, presented to an

emergency department with lethargy and a grossly dilated right pupil. Trauma was ruled out.

A CT scan revealed a right-sided subdural hematoma with mid-line shift. The infant’s

international normalized ratio (INR) was over 10.9 and his prothrombin time (PT) was over 120

seconds. Vitamin K was administered and the infant underwent emergency surgery.

The estimated basal metabolic requirement (BMR) of the infant brain, which weighs 10-11% of

total body weight, requires 50%-60% of total daily energy. (71) (72) which is far greater than

other mammals. An approximation of vitamins and minerals of animal brains provided in food

composition tables proxies the nutritional composition of human brain (20). The rapidly

developing fetal brain is theorized to have high nutrient requirements.

A report of 10 infants (mean gestational age: 30 weeks; range 25-40 weeks) with zinc deficiency

manifesting as erosive, impetiginized periorificial dermatitis at 10 weeks of age (corresponding

to gestational age of 41.4 weeks) was reported from Hamburg, Germany. Initially the cutaneous

15
lesions were misdiagnosed as eczema or impetigo in 8 of the 10 infants and treated with topical

cortico-steroids for a mean of 4 weeks before the correct diagnosis was established by

decreased serum zinc levels. All infants were exclusively breast-fed. Due to the infants rapid

growth, there was in acceleration in zinc requirement. All 10 infants had serum zinc levels

below the normal range of 720-1570 ug/L, ranging from 159 to 567 ug/L. Breast milk zinc levels

were found to be below the normal range of 784-2416 ug/L in 3 of the mothers and 7 of the

mothers did not have levels drawn. Two of the 3 mothers had serum zinc levels below the

normal range of 600-900ug/L; the first with 416 ug/L and the second mother with 548 ug/L.

Symptoms resolved with oral zinc supplementation. The zinc levels of mature breast milk are

lower than zinc in cow’s milk (1.18 mg/L vs. 3.9 mg/L) and further decrease during lactation.

(73)

From a study of 158 infants, aged 6 months, the prevalence of zinc deficiency was investigated

by feeding modality: exclusively breast fed, formula fed and mixed fed. Investigators found

14.9% zinc deficient in breast fed infants, 5.3% in formula bed infants and 2.9% in mixed fed

infants. A higher proportion of mothers of breast fed infants were found to be zinc deficient.

(74)

In the resource-poor community of Maracaibo, Venezuela the macronutrient content of breast

milk from undernourished mothers was studied. Forty samples of breast milk were obtained

from 20 undernourished mothers and 20 well-nourished mothers who had children, aged 15

16
days to 6 months, in the Emergency room of a pediatric ward. (62 Alvarez) Data are provided

in Table 7. This study was a prospective study with no experimental and comparative analysis

between the mothers’ nutritional condition and the macronutrients found in breast milk of two

groups of women. (62) However, breast milk of poorly nourished mothers provided 20%

fewer calories than well-fed women.

Pregnant women in resource-poor areas are at risk for multiple micronutrient deficiencies and

indicators of low vitamin B-12 status have been associated with adverse pregnancy outcomes,

including anemia, low birth weight and IUGR. To evaluate whether a daily oral vitamin B-12

supplementation during pregnancy increases maternal and infant measures of vitamin B-12

status, researchers in Bangalore, India randomly assigned women to either a Vitamin B-12

supplement or placebo. Women in both groups received iron and folic acid supplements.

Table 8 provides data. (63)

In a clinical report from Ankara, Turkey, 20 infants (11 girls, 9 boys) with a mean age of 6.65

+/- 4.5 months were evaluated for vitamin B 12 statuses. All infants were breast fed,

documented to be vitamin B-12 deficient and presented with various symptoms: 30% had

infections; 25% presented with pallor; hypotonia and neuro-developmental delay were

identified in 25%, 20% refused solid food and/or to suck, failure to thrive was found in 15% and

fatigue in 10%. All mothers were identified to be vitamin B 12 deficient due to low socio-

economics, living in resource-poor rural areas. (15) Vitamin B 12 can present as failure to

17
thrive (FTT) in the infant in as short a time as 2 months postnatal life in the full term infant

exclusively breast fed infant with a rapidly developing brain.

Experts suggest it is useful to categorize nutrients into 2 groups during lactation. Group I

nutrients (thiamin, riboflavin, vitamin B-6, choline, retinol, vitamin A, vitamin D, selenium and

iodine) are of the most interest in public health nutrition because their secretion into milk is

rapidly and/or substantially reduced by maternal depletion. Conversely, maternal

supplementation with these nutrients can increase breast milk concentrations and improve

infant status. In contrast, the concentration of Group II nutrients (folate, calcium, iron, copper

and zinc) in breast milk is relatively unaffected by maternal intake or status; the mother

gradually becomes more depleted when intake is less than the amount secreted in milk, add

maternal supplementation benefits the mother rather than the infant. (2)

Breast milk output is lower in malnourished women by 30%. This reduction corresponds to a

lower ingestion of immunoglobulins by the infants of malnourished women. (69). The serum

and human milk antimicrobial antibody titers were measured longitudinally in 17 malnourished

and 14 control Zairian women during 6 to 18 months of lactation to test whether malnutrition

was associated with an impaired secretory antibody response. No decrease in antibody content

was found in the malnourished women when compared with controls. (69) Improving the

maternal diet can help foster antibody production.

18
During a prospective evaluation of a malaria prophylaxis program in a refugee population in

north western Thailand between 1987 and 1990 an extremely high infant mortality rate (18%)

was documented despite good access to health care. Infantile beriberi (thiamine deficiency)

was identified as causing 40% of all infant mortality. The likely cause was thiaminase activity

from raw fish, a typical dietary item, consumed by the lactating women. Vitamin B1 deficiency

was detected in 60% of the plasma samples of the breastfeeding mothers. Other sources of

thiaminase include betel nuts and ferns besides raw fish and raw shellfish. (17)

Vegan diets are known to be deficient in several key nutrients. In a review of the literature of

nutritional adequacy in vegetarian women, vitamin B 12 deficiency among pregnant women

ranged from 17 to 39%, dependent on the trimester. (61) The deficiency prevalence among

breast-fed infants reached 45%.

In a report from a hospital in Prague, Czech Republic, pediatricians followed 40 children who

were referred for FTT. Serum vitamin B 12 (Cbl) of the 40 lactating asymptomatic women

showed levels at 122 +/-52 ng/L (normal range 250-900 ng/L) with breast milk levels of vitamin

B 12 at 64+/- 17 ng/L. Seventeen infants who were profoundly deficient in Cbl with serum

levels of 69 +/-17 ng/L and 23 infants with mild Cbl deficiency serum levels were noted to have

levels at 167 +/- 40 ng/L. Maternal Cbl deficiency may be caused by achlorhydria, Helicobacter

pylori infection, celiac disease, Crohn’s disease, and pancreatic insufficiency, treatment with

proton pump inhibitors or insufficient vitamin B12 from servings of animal proteins or a vegan

diet. (75) Cbl deficiency in adults may present as megaloblastic anemia, polyneuropathy, and

19
subacute combined neuro-degeneration of the spinal cord, dementia or depression. The

clinical impairment of the adult nervous system develops slowly over months or years. In

contrast vitamin B 12 deficiency can cause severe impairment in the neonate who is undergoing

rapid growth and may present within weeks. Anthropometrics- weight and length- begins to

decline long before other clinical presentation appears. FTT was present in 15 of the 17

severely deficient infants. Maternal Cbl deficiency can also be caused by insufficient Cbl

absorption. In this group of subjects only 6 (15%) of mothers were vegetarian. (16)

An investigation by Dijkhuizen (11) et al in West Java, Indonesia of 155 lactating mothers and

their healthy infants were assessed anthropometrically and biochemically via serum, urine and

breast milk samples for vitamin A and zinc. They demonstrated nutritional deficiencies in the

mother and infant do not have parallel biochemical parameters. The infants on physical

examinations were designated as appearing “healthy”. Data are provided in Table 9. (11)

Encouraging healthy omega 3 fats alters the saturated fatty acid profile of milk and can improve

omega 3 fatty acid delivery to the breast-fed infant. (1) (64) (65) Supplementation with

vitamin C and E also improves the total antioxidant content of human breast milk. (66)

Maternal diet influences iodine content of breast milk and is highly variable. (67). While

efforts to eradicate iodine deficiency have been successful with the use of iodized salt, pockets

of deficiency still exist. (76)

20
Research demonstrates food flavors are transmitted via amniotic fluid during pregnancy and

postpartum, via breast milk. (77). There is a high probability that alcohol ingestion during

lactation is also influences the neonatal palate as well as the reward centers in the brain.

There is genuine concern that the additive properties of alcohol begin early and increase the

risk of alcohol addiction later in life. (78) (79) (80) Alcohol has been shown to disrupt the

hormonal milieu of the lactating woman which diminishes the milk supply. (81) A small

amount of alcohol before breast feeding was once thought beneficial however this practice is

no longer endorsed.

Emerging evidence strongly suggests wide-reaching benefits of adequate supplementation of

vitamin D 1, 25 (OH) 2D pre-conceptually through to lactation. (82) Enhanced knowledge

about the functions of this preprohormone indicate the potential to reduce the incidence of

preeclampsia, a major morbid condition of pregnancy and preterm birth, as well as later

disease states as asthma and multiple sclerosis. (83) Adequate pre-conceptual

supplementation with vitamin D is likely to become as health-enhancing as folic acid was in the

early 1990’s.

Consequences of not acknowledging breast milk is not always “perfect”

As a result of our review of the literature, we suggest that human breast milk is more accurately

termed “conditionally perfect” rather than “perfect” and the condition is based on the maternal

diet. It would be hoped that all persons have an adequate food intake which would enhance

health and prevent disease however the evidence this does not happen is well appreciated.

21
What is known about dietary improvement is that some of the most motivated persons are

pregnant women or those planning pregnancy—to optimize fetal development.

When the question is asked: How can breast milk contain all the required nutrients for the

neonate from a woman who suffered from some degree of uncorrected gestational

malnutrition?

Honest answer: Breast milk can’t deliver adequate amounts of nutrients and energy to the

developing neonate without an aggressive nutritional repletion plan for the mother.

Women have heard the message “breast milk is perfect infant nutrition” and have no reason to

believe differently; but armed with knowledge that what they eat makes the crucial difference

of quality, dietary improvement should occur.

At risk mothers include those who have experienced HG, have multiple gestations, previously

bariatric surgery or those with financial hardship or other situations of nutritional compromise

not included herein. Nutrient deficiencies are cumulative nutritional insults which are quietly

bestowed to the conceptus and then to the newborn as well as cognitive functioning and brain

growth. It is conceivable these deficits underlie the origins of autism, an expensive public

health condition. More research is required to adequately address this problem.

22
It is important the lactating woman and all health care professionals be cognizant of current

science regarding breast milk’s level of vitamin D, iron, iodine, vitamin K and other nutrients.

(1 ) (3) (4) (5) (6) (7)(9) (68) (74) (81) (82) Perpetuating the myth that all breast milk is

“perfect” does nutritive injustice to the breast-feeding dyad as well to society.

23
 Breast milk is conditionally perfect

(c) 2017

Miriam Erick, MS RDN CDE LDN

Department of Nutrition
Brigham and Women’s Hospital,
Boston MA 02115 USA

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Author extends appreciation to Jean T. Cox, MS RD, University of New Mexico, Albuquerque,

NM for translating reference # 32.

34
Table 1 Lifestyle factors which impact the nutritional status of females

Preconception Pregnancy Postpartum

Eating disorders (e.g. Unresolved pre- Unresolved
anorexia nervosa, conceptual nutritional maternal nutritional
bulimia) (21, 22) issues issues

Planning for
pregnancy with Multiple gestation:
inadequate twins, triplets,
nutritional quadruplets,
supplementation: Quintuplets, sextuplets
folic acid. Other:
choline, iron, DHA,
iodine, vitamin D
(23) Hyperemesis
gravidarum (37 Fejzo)
Not at desirable (38 Fejzo)
body weight
Pregnancy (39)
Nutrient deficiencies Nutrient deficiencies Nutrient deficiencies
related to bariatric related to bariatric related to bariatric
surgery (24-34) surgery (40-43) surgery when
commencing
Inadequate oral lactation (44-45)
contraception after Complications arising
bariatric surgery during pregnancy (e.g.
(35) gallstones, trauma)

35
Poorly controlled Women who are
maternal medical pregnant and also
conditions: (e.g. breast feeding another
Crohn’s disease, child
ulcerative colitis,
metabolic disorders -
PKU, MSUD

Significant food
allergies without
supplementation

Poverty/food Poverty/food Poverty/food

insecurity/ insecurity/displaced insecurity/displaced
displaced persons persons (36) persons (36)
(36)

Knowledge deficit Knowledge deficit Knowledge deficit

about nutritional about nutritional about nutritional
profile of human profile of human profile of human
breast milk (1-18) breast milk (1-18) breast milk (1-18)

36
Table 2. Micronutrient status of persons before and after weight loss surgery (WLS) (25)

Micronutrient Pre WLS incidence of Post WLS incidence of

deficiency deficiency
Thiamin As high as 29% <1%-49%
Vitamin B 12 2-18% < 20% in RYGD,
4-20% in SG
Folic acid 54% 65%
Iron 45% 14%: AGB
< 18%: SG
13-62%: BPD
8-50%:DS
Vitamin D 90% Up to 100%
Calcium 66.7%
Vitamin A 14% Up to 70% within 4 years
Vitamin E 2.2% No data
Vitamin K No data No data
Zinc 28%, Up to 70% BPD/DS
40% RYGB
74% in those with BPD 19% SG
34% AGB
Copper 70% in those with BDP As high as 90%

(abbreviations:

BDP; biliopancreactic/duodenal switch) (RYGB: roux-en-y gastric bypass)

(SG: sleeve gastrectomy) (AGB: adjustable gastric band)(DS: duodenal switch)

37
Table 3 Nutrient means considered deficient during pregnancy

Nutrient Amount of Trimester 1 Trimester 2 Trimester 3 Non pregnant

nutrient in (n=132) (n=198) (n= 233 women
prenatal (n=83)
supplement
Niacin 20 mg 3.7 +/- 0.6 3.4 +/- 0.6 3.2 +/- 0.7 5.2 +/- 0.2
(ug/mL)
range 3.1-5.0 1.9-4.1 1.9-4.1 3.5-6.4
Thiamin 3.0 mg 32 +/- 8 33 +/- 9 34 +/- 11 48 +/- 4
(ng/mL)
range 18-48 20-49 20-54 26-71
Vitamin B 12 12 mcg 306 +/- 180 275 +/- 162 228 +/- 130 366 +/- 77
(pg/mL)
(ck unit)
range 116 – 604 99 – 558 86 – 437 116 - 660
Vitamin A 5000 IU 32+/- 9 32+/- 8 31 +/- 8 44 +/- 7
(ug/dL)
range 18 – 45 20 – 47 18 -47 27 - 84

(51)

38
Table 4 Incidence of night blindness in pregnant women globally

Region of the World % night blindness in pregnant Serum retinol < 0.70 umol/L
women
Globally 7.8% 15.3%
(6.5-9.1) (6.0-24.6)
Africa 9.4% 14.3%
(8.1-10.7) (9.7-19.0)
Americas and the Caribbean 4.4% 2.0%
(2.7-6.2) (0.4-3.6)
Asia 7.8% 18.4%
(6.6-9.0) (5.4-31.4)
Europe 2.9% 2.2%
1.1-4.6) (0.0-4.3)
Oceania (islands in the Pacific 9.2% 1.4%
Ocean) (10.3-18.2 (0.0-4.0)

(12)

39
Table 5 Incidence of Iodine, zinc and iron deficiencies in pregnant women globally

Region of the World Iodine Zinc Iron deficiency

anemia
(Hgb < 110g/L)
Globally 0.9% 33.3% 15.3%
(0.1-1.8) (29.4-37.1) (6.0-24.6)
Africa 2.1% 41.6% 14.3%
(1.0-3.1) (34.4-44.9) (9.7-19.0)
Americas and the 0.6% 15.6% 2.0%
Caribbean (0.0-1.3) (6.6-24.5) (0.4-3.6)
Asia 0.5% 33.5% 18.4%
(0.0-1.3) (30.7-36.3) (5.4-31.4)
Europe 0.7% 14.9% 2.2%
(0.0-1.5) (0.1-29.7) (0.0-4.3%)
Oceania (islands in the 0.5% 12.6% 1.4%
Pacific Ocean) (0.1-1.0) (6.0-19.2) (0.0-4.0)

(12)

40
Table 6 Nutritional composition of human milk from well-nourished women

Nutrient Colostrum Transitional milk Mature milk

(per deciliter) (1-5 days) (7 - 14 days) (> 30 days)
WATER SOLUBLE
VITAMINS
Vitamin B1 (ug) 1.9 5.9 14
Vitamin B2 (ug) 30 37 40
Niacin (ug) 75 175 160
Pantothenic acid (ug) 183 288 246
Biotin (ug) 0.06 0.35 0.6
Folic acid (ug) 0.05 0.02 0.14
Vitamin B12 (ug) 0.05 0.04 0.1
Vitamin C (mg) 5.9 7.1 5
FAT SOLUBLE
VITAMINS
Vitamin A (ug) 151 88 75
Vitamin D (ug) -- -- 0.04
Vitamin E (mg) 1.5 0.9 0.25
Vitamin K (ug) -- -- 1.5
MINERALS
Calcium (mg) 39 46 35
Chloride (mg) 85 46 40
Copper (ug) 40 50 25-40
Iodine (ug) 12 n/a 11
Iron (ug) (ck unit) 70 70 100
Magnesium (mg) 4 4 4
Phosphorous (mg) 14 20 15

41
Potassium (mg) 74 64 57
Sodium 48 29 15
Zinc (ug) 540 n/a 120
OTHER
Carnitine nmol/mL 115 n/a 70-95
Cholesterol (mg) 27 16
Calories 57– 58 63 65
Adapted from (60)

Table 7 Maternal dietary intake and nutritional profile of breast milk from poorly nourished
breastfeeding women (62)

Characteristic Undernourished (A) Adequately nourished (B)

N= 20 N=20
Maternal weight 41.06 +/- 1.3 kg 61.2 +/- 1.2 kg
Fat content of breast milk 3.8 +/- 0.32 g/dL 5.5 +/- 1.08 g/dL
Protein content of breast milk 1.8 +/- 0.21 g/dL 2.4 +/- 0.32 g/dL
Carbohydrate content of 6.06 +/- 0.43 g/dL 5.7 +/- 0.45 g/dL
breast milk
Caloric content of breast milk 65.92 +/- 15.16 kcal/L 83.27 +/- 9.4 kcal/L
Portions of milk (by FFQ) 4 or 20% 10 or 50%
Portions of meat 2 or 10% 9 or 45%
(by FFQ)
Portions of eggs (by FFQ) 3 or 15% 13 or 65%
Portions of sugar and flour (by 15 or 75% 13 or 65%
FFQ)
Portions of fruit (by FFQ) 14 or 70% 8 or 40%

42
Table 8 Impact of maternal Vitamin B-12 supplementation on breast milk and infant serum
(63)

Characteristic N= 183 N= 183

From < 14 weeks gestation to 50 ug vitamin B 12 Placebo
6 weeks postpartum
2nd Trimester serum 216 pmol/L 111 pmol/L
3rd Trimester serum 184 pmol/L 105 pmol/L
Breast milk @ 6 weeks 136 pmol/L 87 pmol/L
IUGR 25% (33 of 131 babies) 34% (43 of 125 babies)
Infant vitamin B 12 level 199 pmol/L 139 pmol/L

43
Table 9 Comparison of maternal vs. neonate nutritional deficiencies

N= 155 mother-infant pairs

Nutrient % of mothers affected % of infants affected

Vitamin A deficiency 18 54
Zinc deficiency 25% 17%
Iron deficiency 50% n/a

(11)

44
Miriam Erick Conflict of Interest

Miriam Erick is also a book author and receives royalties from Managing Morning Sickness and Take Two
Crackers and Call Me in the Morning! a real-life guide for surviving morning sickness. She also receives
Honoria for presentations.

45