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Nutrition During Pregnancy and Lactation: Exploring New

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Nutrition During Pregnancy and Lactation: Exploring New Evidence: Proceedings of a Workshop

New Developments and Emerging Topics

To set the stage for the second day of the workshop, Anna Maria
S­iega-Riz of the University of Massachusetts Amherst and chair of the
workshop planning committee indicated that many of the topics to be dis-
cussed were not included in the Nutrition During Pregnancy (IOM, 1990)
or Nutrition During Lactation (IOM, 1991) reports. The sessions were
intended to be broad in nature.
Over the past several decades there have been advancements in our
understanding of the relationships between nonnutritive factors associated
with diet and maternal and fetal health during pregnancy, and maternal
and infant health during lactation. Although there have been long-standing
recommendations on caffeine intake during pregnancy and lactation, the
landscape of caffeine-containing products has dramatically changed, which
has given rise to new considerations. The microbiome has also come to the
forefront, with evidence to suggest that maternal diet may play a key role
in its formation. The interplay between maternal metabolism and dietary
composition has also been explored, with evidence to suggest it has an influ-
ence on bioactive compounds in breast milk, which in turn can influence
infant growth and development. The fifth session of the workshop, moder-
ated by Deborah O’Connor, interim chair and professor in the Department
of Nutritional Sciences at the University of Toronto, explored these select
topics where new development and evidence has emerged. Highlights from
the session presentations are presented in Box 6-1.

71
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72 NUTRITION DURING PREGNANCY AND LACTATION

BOX 6-1
Highlights from the Session 5 Presentations

• Current recommendations suggest caffeine intake of less than 200 and

300 mg/day are generally safe during pregnancy and lactation, respectively
(Thorlton).
• More evidence is needed to understand caffeine sensitivity, consumption
practices, and prevalence of use, given the potential for reporting biases and
inaccuracies (Thorlton).
• A host of factors affect caffeine metabolism, including genetics (Thorlton).
• Evidence from both human and nonhuman primate studies suggest that a
maternal high-fat diet during pregnancy affects the composition of the infant’s
gut microbiome (Aagaard).
• Evidence from nonhuman primate models suggest the maternal imprint on her
offspring’s microbiome is long lasting and potentially irreversible (Aagaard).
• Found both in breast milk and amniotic fluid, human milk oligosaccharides may
play a fundamental role in establishing the infant’s microbiome and promoting
gut integrity (Aagaard).
• Breastfeeding appears to have a protective effect against childhood obesity
risk associated with sugar-sweetened beverage consumption (Goran).
• Human milk oligosaccharide concentrations are highly variable between
women, are stable over the course of a day, and change over the course of
lactation (Goran).
• Breast milk fructose concentrations are positively associated with measures
of infant body composition (Goran).

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.

CAFFEINE IN PREGNANCY AND LACTATION: WHAT IS NEW?

Janet Thorlton, clinical associate professor with the Department of
Health Systems Science, Urbana Campus at the University of Illinois at
Chicago College of Nursing, provided remarks on new developments
­
related to caffeine. Her presentation covered current recommendations
and resources for monitoring intake, changes in the landscape of products,
regulations and labeling, caffeine metabolism, and adverse effects.

Caffeine Intake Recommendations and Monitoring

Caffeine is the most widely consumed psychostimulant worldwide. It
is naturally found in coffee, tea, and chocolate and is added to a variety of

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NEW DEVELOPMENTS AND EMERGING TOPICS 73

foods and beverages. Caffeine content varies, with a regular 12-ounce soft
drink containing up to 40 mg and 8 oz of tea and coffee having up to 50
and 100 mg, respectively. The caffeine content of energy drinks can range
from 40 to 250 mg per 8 oz. In addition to being in the food supply, caffeine
is found in some medications, cosmetics, and supplements, noted Thorlton.
Caffeine has been classified as Generally Recognized as Safe for gen-
eral consumption up to 400 mg/day. For the past 30 years, caffeine intake
recommendations for pregnant and lactating women have been less than
200 and 300 mg/day, respectively. Intake recommendations are further
reduced for lactating women whose infant is newborn or preterm. Despite
the long-standing recommendations, Thorlton indicated controversy still
exists regarding the safety of caffeine exposure during pregnancy.
Thorlton highlighted some key resources that can be used to monitor
caffeine consumption patterns. Related to safety, the Center for Food Safety
and Applied Nutrition Adverse Event Reporting System tracks adverse
event reports related to foods, cosmetics, or dietary supplements. Two
nationally representative surveys collect information related to caffeine:
Kantar Worldpanel (a market research firm monitoring worldwide beverage
consumption) and the National Health and Nutrition Examination Survey
(NHANES). Nevertheless, as the market is rapidly changing, the patterns of
use of caffeine-added products are not well understood. Estimating expo-
sure to caffeine from foods, beverages, and supplements poses challenges,
said Thorlton. More evidence is needed to understand caffeine sensitivity,
consumption practices, and prevalence of use given the potential for report-
ing biases and inaccuracies.

Changes in the Landscape of Caffeinated Products

The variety of caffeinated products that have been introduced to the
market has dramatically changed the caffeine landscape. “In the past
20 years, caffeinated energy drinks, sports drinks, juices, and waters have
been introduced,” said Thorlton. Popular caffeinated energy drinks may
contain carbohydrates and a mixture of ingredients to promote a more
powerful stimulant effect.
Thorlton presented a brief timeline of events to provide context for how
the market for caffeinated products was able to expand. She began in 1994,
with the introduction of the Dietary Supplement Health and Education Act
(DSHEA), which she suggested allowed for the proliferation of new types of
caffeinated products to enter the market beginning the mid-1990s. Around
2010, amid reports of adverse events, the U.S. Food and Drug Administration
(FDA) began investigating the labeling of caffeinated products. The Institute
of Medicine released a report on caffeine safety in 2014 (IOM, 2014). In
2015, FDA began warning consumers about pure synthetic c­affeine pur-

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74 NUTRITION DURING PREGNANCY AND LACTATION

chased from the Internet, which may be intended for cosmetic purposes rather
than human consumption. For safety reasons, FDA has asked manufacturers
to voluntarily stop making superconcentrated forms of ­caffeine available. To
better understand caffeine metabolism, FDA has recently released guidance
on the inclusion of pregnant women in clinical trials.

Regulations and Labeling of Caffeinated Products

The dietary supplement market has grown substantially over the past
30 years. Since the passage of the DSHEA, the industry has grown from
a $4 billion market with approximately 4,000 products available to a
$40 billion market representing more than 90,000 products, some of which
contain caffeine, said Thorlton.
FDA regulates dietary supplements and medications differently. At
present, dietary supplements are regulated under the DSHEA, although
FDA is currently considering strengthening regulations and oversight, indi-
cated Thorlton. Product safety and correct labeling is the responsibility
of the dietary supplement manufacturers. For some caffeinated products,
such as certain energy drinks, manufacturers have the option to market
the product as a dietary supplement or as a food and beverage product.
The decision has implications for regulations and labeling. Dietary supple-
ments are regulated under the DSHEA and contain a Supplement Facts
panel, whereas foods and some beverages are regulated under the Food,
Drug, and Cosmetics Act and bear Nutrition Facts panels. Thorlton noted
that individuals using Supplemental Nutrition Assistance Program (SNAP)
benefits, for instance, would be able to use their benefits to purchase an
energy drink containing a Nutrition Facts panel, but would not be able to
purchase an energy drink containing a Supplement Facts panel. She also
cautioned that supplement labels can contain fine print with important
details. In one example, a product included a footnote that provided the
allergen information and recommended the product was not suitable for
children or pregnant women. Concern has been raised about consumer mis-
interpretation of labels, especially for products in which an entire container
is often consumed at one time despite it containing two servings. To address
these concerns, manufacturers are now required to clearly label the serving
size, calories, and nutrients for the entire container rather than per serving.

Caffeine Metabolism
There are many factors that affect caffeine metabolism, clearance, and
pharmacokinetics, said Thorlton. One such factor is genetic variability.
This variability can affect the binding of caffeine to brain receptors, which
in turn influences the experienced effect. People with the polymorphism

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NEW DEVELOPMENTS AND EMERGING TOPICS 75

ADORA2A have been found to be caffeine sensitive. Genetic variability

also influences the activity of CYP1A2, an enzyme responsible for metabo-
lizing 95 percent of ingested caffeine. This polymorphism determines if a
person is a fast or slow metabolizer of caffeine. In addition to genetics,
alcohol intake, dietary factors, smoking, certain liver disease, and use of
oral contraceptives can each affect caffeine clearance, said Thorlton.
Pregnancy affects caffeine clearance. Where in nonpregnant adults, caf-
feine has a half-life of approximately 3–4 hours, the half-life for caffeine
in pregnant women increases across trimesters and can last 9–11 hours.
Caffeine crosses the placental barrier, and the fetus relies on maternal
clearance.
The complexities of lactational pharmacology make it difficult to dis-
cern the implications of caffeine intake during lactation. FDA has encour-
aged the inclusion of lactating women in clinical trials to better characterize
effects in this group. Available evidence suggests that the iron content of
breast milk is decreased among women who chronically consume coffee.
While occasional caffeine intake is not contraindicated, chronic maternal
intake has the potential to increase plasma levels among newborns.

Adverse Effects of Caffeine Intakes

Recent studies, reviews, and meta-analyses have explored the pos-
sible adverse health effects of caffeine intake during pregnancy and lacta-
tion. Sasaki et al. (2017), for instance, found that pregnant women who
did not smoke, had caffeine intake above 300 mg/d, and had the genetic
­polymorphism for rapid caffeine metabolism were at increased risk of hav-
ing an infant with decreased birth size. In their review of caffeine safety,
Temple et al. (2017) identified pregnant women as a population group
in which caffeine consumption could be harmful. A systematic review
concluded that caffeine intake of 300 mg/day is generally not associated
with adverse health effects among healthy pregnant women (Wikoff et al.,
2017). For lactating women, McCreedy et al. (2018) concluded the avail-
able evidence on health effects of maternal caffeine intake on the breastfed
child was limited and inconclusive. There have been suggestions that sug-
ared beverages are a bigger threat to reproductive success than caffeinated
beverages, said Thorlton.

MATERNAL DIET DURING PREGNANCY AND

LACTATION AND THE INTERACTION WITH
THE DEVELOPING INFANT MICROBIOME
“We know that the in utero environment shapes our metabolic heredi-
tability in very unexpected and very creative ways,” said Kjersti Aagaard,

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76 NUTRITION DURING PREGNANCY AND LACTATION

the Henry and Emma Meyer Professor Chair in Obstetrics and Gynecology
at the Baylor College of Medicine and Texas Children’s Hospital. Over the
course of her presentation, Aagaard provided an overview of interactions
between the maternal diet and the developing infant microbiome, drawing
on evidence in humans and nonhuman primates. She also discussed the
relationships between maternal intake and human milk oligosaccharides
(HMOs).

Evidence on the Developing Microbiome in Humans

Maternal exposures have the potential to influence the neonatal and
infant microbiome in different ways, such as through intrauterine coloni-
zation, immune education, and colonization resistance (the occupying of
specific microbes in a niche space). Although some vertical transfer of live
microbes from the pregnant women to the developing fetus likely happens,
the data supporting this are limited, indicated Aagaard. She suggested
that focus should be given to how tolerance to commensal microbes is
acquired, and how and when immune differentiation between these com-
mensal microbes and pathogenic microbes occurs. Equally important are
investigations into understanding the process of how and when coloniza-
tion resistance to pathogenic microbes occurs, and understanding the role
of commensal microbes in occupying these niches and thereby limiting the
capacity of pathogenic microbes in competing for nutrients and substrates
in body niches, Aagaard said.
Aagaard’s earlier work explored the constituents and activity of ­vaginal
microbiomes of pregnant women. Compared to nonpregnant women, preg-
nant women’s vaginal microbiomes had a significantly distinct clustering
and were both less rich and less diverse (Aagaard et al., 2012). Although
reduction in microbiome diversity has been found to lead to disease states
for other conditions (e.g., inflammatory bowel disease), it appears to be
normal for pregnancy and changes as a women transitions from early
to late pregnancy, then again to term delivery and postpartum. Aagaard
explained it happens through an ecological process of microbial ­coexclusion
and co-occurrence.
Vaginal microbiomes during pregnancy are not the same as those found
in the infant’s gut during the first week of life (Aagaard et al., 2012; Chu
et al., 2017; Jost et al., 2012). For instance, Lactobacillus species, which
are dominant in the vaginal microbiome, are not the dominant genera
present in the neonatal gut microbiome. This finding led Aagaard’s group
to explore other sources and modifiers of the neonatal microbiome, includ-
ing the placenta (Aagaard et al., 2014; Prince et al., 2016; Seferovic et al.,
2019) and the maternal diet. They found that the neonates of mothers
who consumed more than 30 percent of energy from fat (high-fat diet) had

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NEW DEVELOPMENTS AND EMERGING TOPICS 77

different gut microbiomes at birth than infants of mothers who consumed

lower fat diets, and these changes in the microbiome community appeared
to persist over time (Chu et al., 2017). The infants in the study, however,
were breastfed, which made it difficult to determine if the findings stemmed
from gestation or lactation exposures.
To further explore the relationship between maternal dietary fat intake
and infant gut microbiome, Aagaard’s team conducted a population-based
prospective, longitudinal cohort (Chu et al., 2017). Maternal intake of a
high-fat diet was found to decrease the amount of Bacteroides species in
infant stool at 6 weeks of age, whereas ever being exposed to infant formula
increased it. Aagaard reported that maternal high-fat diet and ever consum-
ing infant formula were stronger drivers of differences in the amount of
Bacteroides species in the infant gut than Cesarean delivery.

Evidence from Nonhuman Primate Models

Using the Japanese macaque as a nonhuman primate model, Aagaard’s
group assessed the influence of the maternal diet on the infant’s ­microbiome
and explored whether the effects persisted in the long term (Ma et al., 2014;
Pace et al., 2018; Prince et al., 2019). Dams were fed either a control diet
(13 percent energy from fat) or a “great American diet” (35 percent energy
from fat). Over time, approximately one-third of the monkeys did not
develop obesity despite being on the higher-fat diet (Harris et al., 2016;
Suter et al., 2011, 2012), which allowed Aagaard’s team to tease apart
effects of the high-fat diet as opposed to obesity. For the fetal studies, the
monkeys are delivered at the equivalent of 32 weeks gestation for humans
(Aagaard-Tillery et al., 2008; McCurdy et al., 2009). As pertained to the
work on the effect of the maternal high-fat diet exposure during gesta-
tion, they compared the fetal microbiomes to that of their siblings and
non­siblings, which did not undergo fetal necropsy but rather underwent
necropsy at 1 or 3 years of age (Ma et al., 2014; Pace et al., 2018; Prince
et al., 2019). They found that the fetal microbiome was sparse and aligned
closer to the microbiomes of the placenta, followed more distantly by the
maternal sites of the oral, vaginal, and gut communities. The fetal, infant,
and juvenile microbiomes of offspring whose mothers consumed the high-
fat “great American diet” were distinct, even if the offspring consumed a
control diet (Ma et al., 2014; Pace et al., 2018; Prince et al., 2019). This
finding suggests that a maternal high-fat diet has a lasting imprint on the
offspring’s microbiome, said Aagaard. She went on to note that such dif-
ferences were not seen among offspring whose mothers were obese but had
been reverted to a control diet prior to pregnancy.
A follow-up study sought to identify interventions that could correct
the influence of the maternal high-fat diet. Offspring given probiotics in a

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78 NUTRITION DURING PREGNANCY AND LACTATION

symbiotic preparation showed improvements in total cholesterol (Pace et

al., 2018). However, discontinuation of the probiotics or being challenged
with a high-fat diet reversed changes seen with the probiotics. The probiotic
intervention, like the control diet, had no lasting effect on the offspring’s
microbiome, further suggesting that the maternal imprint does not appear
to be reversible (Ma et al., 2014; Pace et al., 2017; Prince et al., 2019).

Maternal Diet and Human Milk Oligosaccharides

Aagaard’s team has also explored whether there are certain expo-
sures in the early life environment that help to shape the neonatal and
infant microbiome via macromolecule substrates, and whether those macro­
molecules are similarly affected by maternal diet. As background, Aagaard
introduced the notion that while human milk is known to be the optimal
nutrition source for infants, the “how and why” this is true remains elu-
sive. She noted that other macromolecules that are found in human milk
include oligosaccharides. Specifically, HMOs are favorable macromolecules
that are, interestingly, indigestible by the infant but serve as substrates
by microbiota. Her team conducted a randomized crossover trial with
two cohorts of lactating women (Mohammad et al., 2011; Munch et al.,
2013) to investigate the effects of different dietary exposures on breast
milk composition, including both HMOs and the microbiome. One cohort
was tested with different carbohydrate sources (glucose versus galactose),
while the other was tested with changes to the energy source (high carbo-
hydrate versus high fat). Maternal intake of different carbohydrate sources
did not change the macronutrient or energy content of the breast milk.
In contrast, high fat intake increased the fat and energy content of breast
milk. Both cohorts revealed differences in HMO speciation content: the
HMO-bound fucose was significantly different between the glucose and
galactose exposures, whereas HMO-bound sialydase was different between
the high-carbohydrate and high-fat exposures. Of note, Aagaard’s group
found significant associations between the concentration of HMO-bound
fucose and the abundance of fucosidase (a bacterial gene that digests fucose
moieties) harbored by milk microbiota. These studies collectively reveal a
successive mechanism by which the maternal diet during lactation alters
milk HMO composition, which in turn shapes the functional milk micro-
biome prior to infant ingestion.
Amniotic fluid samples collected mid gestation also appear to contain
certain HMOs, including trisaccharide-2′-fucosyllactose. Aagaard explained
that there are women who do and women who do not secrete fucosyllated
HMOs (i.e., secretors and nonsecretors), which can be predicted from
blood group antigens. The distribution of fucosyllated HMOs in amniotic
fluid was found to follow the population-based estimate, relative to the

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NEW DEVELOPMENTS AND EMERGING TOPICS 79

proportion of predicted secretors and nonsecretors. A second, more detailed

analysis found the HMO 3′-sialyllactose in all 270 amniotic fluid samples
evaluated. The amniotic fluid concentrations of HMOs were lower than
concentrations found in breast milk but higher than concentrations found
in urine. The profile of microbes found in amniotic fluid share similarities
and overlap with microbes found in the neonate’s gut at delivery (Chu et
al., 2017). The presence of HMOs in both amniotic fluid and breast milk
suggest they are fundamentally important in potentially shaping what func-
tions these community members play, said Aagaard. She said HMOs could
play a role in helping low biomass commensal communities colonize, with
potential for colonization resistance of pathogenic microbes, and in devel-
oping gut integrity early in fetal development.

Caveats and Considerations

Aagaard concluded her remarks by noting some key considerations.
She indicated that the metagenetic evidence she presented only reflect the
presence of the microbes—the analyses do not differentiate between live
and dead microbes. Emphasizing the importance of colonization resistance,
Aagaard acknowledged it is unclear at this time the extent to which the
bacteria themselves facilitate this process versus the role of macro­molecules
and small molecule intermediates, including HMOs or other metabolites.
She also suggested that mechanistic evidence is needed to understand
how macronutrients exert different effects. Finally, Aagaard underscored
the importance of further exploration into the metagenome—“how it is
acquired, how it changes, how resilient it is, how resilient it is not, will help
us understand what are the lasting footprints of the mom [on her infant’s
microbiome],” she said.

FRUCTOSE AND OLIGOSACCHARIDES IN HUMAN

BREAST MILK AND THEIR EFFECTS ON INFANT BODY
COMPOSITION AND COGNITIVE OUTCOMES
Michael Goran, professor of pediatrics at Children’s Hospital Los
Angeles, which is affiliated with the Keck School of Medicine at the Uni-
versity of Southern California, explained his interest in understanding
the effects of breast milk sugar content stemmed from an exploration of
modifiable determinants of obesity in children. Beginning with evidence
on the relationships between sugar-sweetened beverages, breastfeeding,
and childhood obesity, Goran’s remarks also provided an overview of
HMOs, fructose exposure and metabolism during infancy, and low-calorie
sweeteners.

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80 NUTRITION DURING PREGNANCY AND LACTATION

Relationships Between Sugar-Sweetened Beverages,

Breastfeeding, and Childhood Obesity
In 2012, Goran’s group published a journal article that explored the
interplay between early introduction of sugar-sweetened beverages, breast-
feeding, and childhood obesity among approximate 1,500 children enrolled
in the Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC) (Davis et al., 2012). The study revealed that breastfeeding
a child for more than 12 months was protective against obesity risk asso-
ciated with sugar-sweetened beverage consumption at 3–4 years of age.
Goran noted that Project VIVA had found that maternal intake of sugar-
sweetened beverages in the second trimester of pregnancy was associated
with markers of obesity in later childhood (Gillman et al., 2017); others
have reported similar findings, he said. “There is certainly evidence now for
a transmission effect of sugars during pregnancy, and data show that the
earlier the introduction during childhood, the bigger the effect on obesity
risk,” said Goran.

Overview of HMOs
Lactose, a disaccharide of glucose and galactose, is the primary sugar
found in human milk at a concentration of 65 g/L. Oligosaccharides con-
sist of different combinations of three or more sugars and are abundant
in human milk, with concentrations similar to that of protein (5–15 ver-
sus 12 g/L, respectively). By contrast, the oligosaccharide content of cow
milk is significantly lower than its protein content (0.05 versus 35 g/L,
respectively). Echoing remarks made by Aagaard, Goran noted that HMOs
are not absorbed, but rather serve as prebiotics that are digested by the
microbes of the infant gut.
Studies have explored differences in HMO concentrations between
and within lactating women. Analyses of data from the Canadian CHILD
Cohort found that women who secreted 2′-fucosyllactose in their breast
milk had different HMO profiles than those who did not secrete it (Azad et
al., 2018). Goran added that 2′-fucosyllactose secretion is genetically deter-
mined. HMO composition appears to be highly variable between women.
Although HMO concentrations for a given women appear stable over the
course of a day, there is evidence that they can dynamically change over
time. For instance, concentrations of 3′-sialyllactose appears to increase
over time, whereas concentrations of 6′-sialyllactose decreases over time.
These two HMOs have similar structures and play a role in delivering
sialic acid for infant brain development. Goran noted that a project is cur-
rently underway investigating HMO compositional changes that occur with
breastfeeding beyond 12 months.

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NEW DEVELOPMENTS AND EMERGING TOPICS 81

Fructose Metabolism and Exposure During Infancy

Despite having the same chemical formula, fructose and glucose have
different metabolic fates. Glucose is used for energy throughout the body.
In contrast, almost all of the fructose consumed is taken up by the liver
in an insulin-independent manner and converted to triglycerides. The tri­
glycerides can either be packaged in very low-density lipoproteins (VLDLs)
and exported out of the liver or remain in the liver. The intake of fruit juice
or beverages containing high-fructose syrup increases the amount of fruc-
tose in the liver, which can lead to the accumulation of fat in the liver and
for more lipids to be in circulation.
An infant’s natural feeding environment does not contain fructose.
Rather, the infant consumes lactose and uses the glucose for energy and the
galactose for brain development. Infants are not born with GLUT-5 trans-
porters needed to absorb fructose. During this time, the fructose will remain
in the infant’s gut and serve as a probiotic to gut bacteria. The machinery
to absorb fructose develops with sufficient fructose intake.
In a small pilot study of 27 lactating women, detectable levels of fruc-
tose were found in breast milk, although the concentrations were variable.
Fructose content of breast milk was positively associated with measures of
infant body composition, including body weight, lean mass, fat mass, and
bone mineral content (Goran et al., 2017).
An acute crossover feeding trial assessed breast milk composition in the
6 hours after lactating women were challenged with a beverage containing
high-fructose corn syrup beverage and a beverage with a noncaloric sweet-
ener (Berger et al., 2018). Breast milk glucose concentrations rose after
consumption of the sugar-sweetened beverage, but was only significantly
different at the 2-hour time point after intake. The rise in breast milk fruc-
tose concentrations were much faster and stayed elevated longer when the
women consumed the high-fructose syrup beverage.
Goran acknowledged that concentrations of breast milk glucose are in
milligrams per milliliter, whereas concentrations of fructose are in micro-
grams per milliliter, which raises the question as to whether such a relatively
low exposure has an effect on the infant. Investigators at the Univer-
sity of California, Los Angeles, have explored this concept, assessing the
effects of different fructose concentrations on preadipocyte gene expression
(­Shepherd et al., 1993). GLUT-4 expression was increased for all fructose
exposures relative to the control condition without fructose. Goran noted
that the increase in GLUT-4 expression could have important implications
for cellular metabolism, adipogenesis, and glucose intolerance.
The Mothers Milk Study, currently in progress, seeks to build and
expand on the findings about breast milk composition and the implica-
tions for children’s health. The study recruited 240 Hispanic mother–infant

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82 NUTRITION DURING PREGNANCY AND LACTATION

dyads and has been collecting maternal milk samples, infant stool samples,
and measures of maternal and infant diet and obesity every 6 months
over the children’s first 2 years of life. The study seeks to find maternal
dietary factors and/or breast milk compounds associated with healthy gut
­bacteria colonization, obesity prevention, and cognitive development pro-
motion. Goran presented some preliminary findings assessing infants in the
first 6 months. Of the 17 most abundant HMOs identified in breast milk
samples, lacto-N-fucopentaose II (LNFPII) is the only one that appeared to
have an inverse relationship with infant weight change in the first 6 months.
The Mothers Milk Study is also investigating different mechanisms
and gut bacteria products that may affect metabolism, brain development,
energy regulation, and infant feeding behaviors. One such analysis under-
way is exploring whether HMO content is associated with food responsive-
ness among infants at 1 month of age. Goran admitted interpretation of
the data are challenging, as food responsiveness at such an early age may
very well be beneficial, despite it being a risk factor for obesity later in
childhood. Another analysis is looking for a relationship between HMOs
and brain development. Animal studies have found significant relationships
between 2′-fucosyllactose and learning, memory, and attention in rodents,
which has led some companies to add it to infant formulas. However, he
indicated that no human studies have established such links. The Mothers
Milk Study data were used to evaluate longitudinal exposure to various
HMOs and their relationships with cognitive, language, and motor out-
comes in the first 2 years of life. The results suggest a positive relationship
between the number of milk feedings and children’s cognitive outcomes at
24 months (Berger et al., 2020). Much of the variation seen was explained
by breast milk concentration of 2′-fucosyllactose, which was significantly
associated with more favorable cognitive test outcomes at 1 month of age.

Low-Calorie Sweeteners
Goran concluded his presentation by discussing low-calorie sweetener
intakes. An analysis of NHANES data found positive relationships between
low-calorie sweetener intake and both energy and sugar intake among chil-
dren. Children who consumed both low-calorie sweetened beverages and
sugar-sweetened beverages consumed more than 400 kcal/day more than
children who only consumed water (Sylvetsky et al., 2019). “Low-calorie
sweeteners are not doing the job they are supposed to do,” said Goran.
Evidence suggests consumption of low-calorie sweeteners is increasing
among pregnant women. Nearly one-quarter of pregnant women in the
United States consume low-calorie sweeteners on a daily basis, primarily
from beverages (Sylvetsky et al., 2019). Infants of women who consumed
more low-calorie sweeteners during pregnancy were at a two-fold increased

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NEW DEVELOPMENTS AND EMERGING TOPICS 83

risk of obesity by 2 years of age (Azad et al., 2016). Goran noted that this
finding, which has been shown in other studies, underscores that maternal
diet during pregnancy can have long-lasting effects on their children. He
also remarked that low-calorie sweeteners are also transferred to infants via
breast milk (Rother et al., 2018).

DISCUSSION
Following Goran’s presentation, he, Aagaard, and Thorlton partici-
pated in a session discussion, moderated by O’Connor. Questions raised
by audience members touched on topics related to maternal intake, breast
milk and infant formula, and fructose.

Maternal Intake
Several of the questions pertained to concepts related to maternal
intake. Siega-Riz wondered if women whose diets are suboptimal enter-
ing pregnancy could alter fetal imprinting if they took probiotics early
and throughout pregnancy. Indicating that pregnant women are generally
motivated to comply with dietary recommendations when they understand
the benefits, Aagaard suggested a more prudent approach would be to
improve dietary intake. From the audience, Patrick Catalano of the Tufts
University School of Medicine added that probiotic trials do not typically
find benefits, and those that do generally report reduced risk of gestational
diabetes. Aagaard responded that many variables could affect the effect of
a probiotic (e.g., dose, strain). Given this complexity, she underscored the
importance of focusing on improving intakes through food, which can feed
the commensal microbiota.
Regarding Aagaard’s suggesting an imprinting of maternal high-fat
diets on the offspring microbiome, Carol Dreibelbis of 1,000 Days asked
if the type of fat affected the infant’s microbiome. Aagaard explained that
quality of fat was embedded, to an extent, in the groupings; women who
consumed fat only from plant sources all fell in the low-fat group. She
acknowledged that it was difficult to tease apart different effects of satu-
rated and unsaturated fat.
On the topic of imprinting, Erica Gunderson of Kaiser Permanente
Northern California, Division of Research, asked if there were human data
on the effects of changing maternal diet during lactation. Aagaard admitted
that, in the nonhuman primate data, it is difficult to differentiate between
effects of diet during gestation versus lactation owing to the inability to
cross-foster in the Japanese macaque. Aagaard questioned the clinical rel-
evance and practical reality of trying to implement specific dietary changes
during lactation, noting that longitudinal studies that have investigated this

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84 NUTRITION DURING PREGNANCY AND LACTATION

raise questions about which dietary changes actually result in beneficial

effects related to changes to the infant microbiome. Gunderson followed up
by asking about the implications for women who had gestational diabetes
who then have high sugar-sweetened beverage intake postpartum. Aagaard
underscored the importance of refocusing women on healthful nutrition
during this life stage. Goran added that there is evidence that high-sugar
diets are associated with greater postpartum weight, while high-fiber diets
are protective. He acknowledged, however, that additional evidence on
these relationships are needed.
An unidentified webcast audience member asked the session speakers if
they would recommend that a woman with obesity still breastfeed even
if she was a heavy consumer of sugar-sweetened beverages or caffeine.
­Thorlton, referring to caffeine intake guidelines she described in her pre-
sentation, noted that scaling back on breastfeeding might be warranted
when the infant is a newborn or preterm. With respect to sugar-sweetened
beverages, Goran indicated the mother should reduce her intake and not
substitute with low-calorie sweetened products. Aagaard said that the rec-
ommendation would not be to breastfeed less. She challenged the concept
of focusing on women with obesity, and suggested that greater attention
needed to be given to nutrition across the life span, including during lacta-
tion. The evidence suggesting that maternal diet affects HMO composition
in breast milk does not speak to the directionality of this effect, “whether
that may in part have some adaptive influence on the baby, we do not know.
But just because it is different does not make it bad,” said Aagaard.

Breast Milk and Infant Formula

Becky Banks, a midwife in private practice, asked the speakers if any
of the breast milk findings they presented differ by whether the milk was
consumed directly from the breast or was expressed. Goran stated that
the Canadian CHILD study found a difference in HMOs between breast
milk from the breast versus expressed breast milk consumed from a bottle.
Aagaard added that there are likely maternal effects. “The source m ­ atters,
and it probably matters not just for the baby, but for the mom,” said
Aagaard.
An unidentified audience member asked Goran to expand on his com-
ment about HMOs being added to infant formula, despite a lack of human
data on their effects. Admitting he was not well versed in the full regula-
tions, Goran noted that 2′-fucosyllactose is approved by FDA as Generally
Recognized as Safe and 3′-sialyllactose has also been recently reviewed for
such approval. Natural breastfeeding cohorts have demonstrated the ben-
efits of these compounds, noted Aagaard. However, she raised questions
about the effect of 2′-fucosyllactose being consumed by infants of non­

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NEW DEVELOPMENTS AND EMERGING TOPICS 85

secretors. O’Connor added that there are studies that have been conducted
in Europe that have explored the addition of HMOs to infant formulas, but
mostly these have looked at safety and effects on growth and not cognitive
outcomes.
Cindy Turner-Maffei of the Healthy Children Project wondered if milk
from mothers who consume low-calorie sweeteners would have a taste
difference. Goran indicated there are anecdotes, but he was not aware of
published literature on the topic.

Fructose
Referring to Goran’s comment about GLUT-5 transporters, Banks
wanted to know when an infant starts absorbing and metabolizing fruc-
tose. Goran stated that the available evidence comes from animal studies,
which suggest GLUT-5 is not active until fructose is introduced in the diet.
He suggested that human-specific data are lacking.
A webcast audience member asked if any fructose is converted to
glucose in the liver. Goran said that in mouse models, low fructose concen-
tration can lead the gut to convert fructose to glucose, but he said that in
humans, fructose reaching the liver will be used for de novo lipogenesis.

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