Vulnerable for Groups

Definition of terms

Infant The term infant is typically applied to very young children under one year of age;
however, definitions may vary and may include children up to two years of age.

Lactation describes the secretion of milk from the mammary glands and the period of time
that a mother breastfeed her young one.

Toddler is when a human child learns to walk, the term toddler may be used instead.

Pregnancy is the term used to describe the period in which a fetus develops inside a
woman's womb or uterus.

Vulnerable (of a person) is one in need of special care, support, or protection because of age,
disability, or risk of abuse or neglect.

Vulnerable groups this is a term applied to groups of people (children, pregnant women, elderly
people, malnourished people, prisoners, migrants and refugees, people who uses drugs, and
people who are ill or immunocompromized, etc.) who, due to factors usually considered outside
their control, do not have the same opportunities as other, more fortunate groups in society.

Introduction to Vulnerable Groups

Vulnerable groups are physically, mentally, or socially disadvantaged persons who may be
unable to meet their basic needs and may therefore require specific assistance.

Persons exposed to and/or displaced by conflict or natural hazard may also be considered
vulnerable.

Vulnerable groups may experience a higher risk of poverty and/or social exclusion.

Vulnerable groups include the economically disadvantaged, racial and ethnic minorities, the
uninsured, low-income children, the elderly, the homeless, those with human immunodeficiency
virus (HIV), and those with other chronic health conditions, including severe mental illness.

It may also include rural residents, who often encounter barriers to accessing healthcare services.

The vulnerability of these individuals is enhanced by race, ethnicity, age, sex, and factors such as
income, insurance coverage (or lack thereof), and absence of a usual source of care.1,4-8 Their
health and healthcare problems intersect with social factors, including housing, poverty, and
inadequate education
Health Domains of Vulnerable Populations

The health domains of vulnerable populations can be divided into 3 categories: physical,
psychological, and social.

Those with physical needs include high-risk mothers and infants, the chronically ill and disabled,
and persons living with HIV/acquired immunodeficiency syndrome.4 Chronic medical conditions
include respiratory diseases, diabetes, hypertension, dyslipidemia, and heart disease. Eighty-
seven percent of those 65 years and older have 1 or more chronic conditions, and 67% of this
population have 2 or more chronic illnesses.9

In the psychological domain, vulnerable populations include those with chronic mental
conditions, such as schizophrenia, bipolar disorder, major depression, and
attention-deficit/hyperactivity disorder, as well as those with a history of alcohol and/or
substance abuse and those who are suicidal or prone to homelessness.4

In the social realm, vulnerable populations include those living in abusive families, the homeless,
immigrants, and refugees.4

The needs of these populations are serious, debilitating, and vital, with poor health in 1
dimension likely compounded by poor health in others. Those with multiple problems also face
more significant comorbidities and cumulative risks of their illness than those experiencing a
single illness.4

Overall, nonwhite women 45 to 64 years of age who are unemployed and uninsured with lower
incomes and education levels tend to report the poorest health status.2
Topic 2: Nutrition During Pregnancy

The Academy of Nutrition and Dietetics recommends the following key components of a healthy
lifestyle during pregnancy:

 Appropriate weight gain

 A balanced diet
 Regular exercise
 Appropriate and timely vitamin and mineral supplementation

Nutritional Needs During Pregnancy

As you probably know, your body goes through lots of physical and hormonal changes during
pregnancy. To fuel yourself and your growing baby, you’ll need to make great food choices from
a variety of sources.

Eating a healthy, balanced diet will help you feel good and provide everything you and your
baby need. The food you eat is your baby’s main source of nourishment, so it’s critical to get all
of the nutrients you need.

The good thing? All of these nutrition guidelines aren’t that hard to follow and provide some
delicious options. Even with cravings (hot sauce on peanut butter, anyone?) you can craft up a
healthy menu in no time.

Increased nutrients

No surprise here: Your body has increased nutritional needs during pregnancy — you’re feeding
a whole new person! Although the old adage of “eating for two” isn’t entirely correct, you do
require more micronutrients and macronutrients to support you and your baby.

Micronutrients are dietary components, such as vitamins and minerals, that are only required in
relatively small amounts.

Macronutrients are nutrients that provide calories, or energy. We’re talking carbohydrates,
proteins, and fats. You’ll need to eat more of each type of nutrient during pregnancy.

Here are some general guidelines on a few important nutrients that will need to be adjusted based
on your needs:

Nutrient Daily requirements for pregnant women

calcium 1200 milligrams (mg)

folate 600–800 micrograms (mcg)

iron 27 mg

protein 70–100 grams (g) per day, increasing each trimester

Most pregnant people can meet these increased nutritional needs by choosing a diet that includes
a variety of healthy foods such as:

 protein
 complex carbohydrates
 healthy types of fat like omega-3s
 vitamins and minerals

What and how much to eat

Your goal? Eat a wide variety of foods to provide everything you and your baby needs. It’s not
that different from a regular healthy eating plan — just amplified a bit.

In fact, current guidanceTrusted Source is to continue to eat as you normally would in your first
semester, then increase 350 calories daily in your second trimester and 450 calories daily in your
third trimester as your baby grows.

As often as you can, avoid overly processed junk foods. Chips and soda, for example, contain no
nutritional value. You and your baby will benefit more from fresh fruits, vegetables, and lean
proteins, such as chicken, fish, beans, or lentils.

This doesn’t mean that you need to avoid all of your favorite foods during pregnancy. Just
balance them with nutritious foods so that you don’t miss any important vitamins or minerals.

Protein

Protein is critical for ensuring the proper growth of baby’s tissues and organs, including the
brain. It also helps with breast and uterine tissue growth during pregnancy.

It even plays a role in your increasing blood supply, allowing more blood to be sent to your baby.

Your protein needs increase during each trimester of pregnancy. Research suggestsTrusted
Source that protein intake during pregnancy should be even higher than some current
recommendations. It’s time to ramp up those shrimp fajitas, pork curries, jerk chicken, and
salmon teriyaki.
You’ll need to eat about 70 to 100 gTrusted Source of protein a day, depending on your weight
and which trimester you’re in. Talk to your doctor to see how much you specifically need.

Good sources of protein include:

 lean beef and pork

 chicken
 salmon
 nuts
 peanut butter
 cottage cheese
 beans

Calcium

Calcium helps build your baby’s bones and regulates your body’s use of fluids. It does a body
good, right?

Pregnant women need 1,000 mg of calciumTrusted Source, ideally in two doses of 500
mgTrusted Source, per day. You’ll likely need additional calcium to supplement regular prenatal
vitamins.

Good sources of calcium include:

 milk
 yogurt
 cheese
 low-mercury fish and seafood, such as salmon, shrimp, catfish, and canned light tuna
 calcium-set tofu
 dark green, leafy vegetables

Folate

Folate, also known as folic acid, plays an important part in reducing the risk of neural tube
defects. These are major birth defects that affect the baby’s brain and spinal cord, such as spina
bifida and anencephaly.

When you’re pregnant, the American College of Obstetrics and Gynecology (ACOG)
recommends 600 to 800 mcg of folate. You can get folate from these foods:

 liver
 nuts
 dried beans and lentils
 eggs
 nuts and peanut butter
 dark green, leafy vegetables
Iron

Iron works with sodium, potassium, and water to increase blood flow. This helps ensure that
enough oxygen is supplied to both you and your baby.

You should be getting 27 mg of iron per day, preferably alongside some vitamin C to increase
absorption. Good sources of this nutrient include:

 dark green, leafy vegetables (noticing a trend with this one?)

 citrus fruits
 enriched breads or cereals
 lean beef and poultry
 eggs

Other considerations

Other nutrients are necessary to keep you thriving during your pregnancy like choline, salt, and
B vitamins.

Aside from eating well, it’s important to drink at least eight glasses of water each day and to take
prenatal vitamins. It’s difficult to obtain sufficient amounts of certain nutrients, including folate,
iron, and choline, from food alone.

Make sure to speak with your doctor about which prenatal vitamins you should take.

Dietary and Caloric Recommendations

To maintain a healthy pregnancy, approximately 300 extra calories are needed each day. These
calories should come from a balanced diet of protein, fruits, vegetables and whole grains. Sweets
and fats should be kept to a minimum. A healthy, well-balanced diet can also help to reduce
some pregnancy symptoms, such as nausea and constipation.

Fluid Intake During Pregnancy

Fluid intake is also an important part of pregnancy nutrition. Follow these recommendations for
fluid intake during pregnancy:

 You can take in enough fluids by drinking several glasses of water each day, in addition
to the fluids in juices and soups. Talk to your health care provider or midwife about
restricting your intake of caffeine and artificial sweeteners.
 Avoid all forms of alcohol.
Ideal Foods to Eat During Pregnancy
The following foods are beneficial to your health and fetal development during pregnancy:

 Vegetables: carrots, sweet potatoes, pumpkin, spinach, cooked greens, tomatoes and red
sweet peppers (for vitamin A and potassium)
 Fruits: cantaloupe, honeydew, mangoes, prunes, bananas, apricots, oranges, and red or
pink grapefruit (for potassium)
 Dairy: fat-free or low-fat yogurt, skim or 1% milk, soymilk (for calcium, potassium,
vitamins A and D)
 Grains: ready-to-eat cereals/cooked cereals (for iron and folic acid)
 Proteins: beans and peas; nuts and seeds; lean beef, lamb and pork; salmon, trout, herring,
sardines and pollock

Foods to Avoid During Pregnancy

Avoid eating the following foods during pregnancy:

 Unpasteurized milk and foods made with unpasteurized milk (soft cheeses, including
feta, queso blanco and fresco, Camembert, brie or blue-veined cheeses—unless labeled
“made with pasteurized milk")
 Hot dogs and luncheon meats (unless they are heated until steaming hot before serving)
 Raw and undercooked seafood, eggs and meat. Do not eat sushi made with raw fish
(cooked sushi is safe).
 Refrigerated pâté and meat spreads
 Refrigerated smoked seafood

Guidelines for Safe Food Handling

Follow these general food safety guidelines when handling and cooking food:

 Wash. Rinse all raw produce thoroughly under running tap water before eating, cutting
or cooking.
 Clean. Wash your hands, knives, countertops and cutting boards after handling and
preparing uncooked foods.
 Cook. Cook beef, pork or poultry to a safe internal temperature verified by a food
thermometer.
 Chill. Promptly refrigerate all perishable food.

Prenatal Vitamin and Mineral Supplements

Most health care providers or midwives will prescribe a prenatal supplement before conception
or shortly afterward to make sure that all of your nutritional needs are met. However, a prenatal
supplement does not replace a healthy diet.
The Importance of Folic Acid

The U.S. Public Health Service recommends that all women of childbearing age consume 400
micrograms (0.4 mg) of folic acid each day. Folic acid is a nutrient found in:

 Some green leafy vegetables

 Most berries, nuts, beans, citrus fruits and fortified breakfast cereals
 Some vitamin supplements.

Folic acid can help reduce the risk of neural tube defects, which are birth defects of the brain and
spinal cord. Neural tube defects can lead to varying degrees of paralysis, incontinence and
sometimes intellectual disability.

Folic acid is the most helpful during the first 28 days after conception, when most neural tube
defects occur. Unfortunately, you may not realize that you are pregnant before 28 days.
Therefore, your intake of folic acid should begin before conception and continue throughout your
pregnancy. Your health care provider or midwife will recommend the appropriate amount of
folic acid to meet your individual needs.

For example, women who take anti-epileptic drugs may need to take higher doses of folic acid to
prevent neural tube defects. They should consult with their health care provider when
considering trying to conceive.
Topic 3: Nutrition and Lactation
INTRODUCTION

Lactation is the secretion of milk by the mammary glands.

Mothers who breastfeed their infants have been characterized as being middle class, married, and
white, and as having some college education and one or two children. Women in other situations
also are breastfeeding their infants, so to assume that an unmarried nonwhite teenager is unlikely
to breastfeed her child is unwise. Some of the greatest increases in breastfeeding initiation rates
occur among nonwhites.1 In one study, there was no difference in breastfeeding duration rates
when low-income, often nonwhite, single women were provided information and support for
breastfeeding during the prenatal and early postpartum periods.3

Factors that influence the decision to breastfeed and its duration are prenatal support and
information,4 support in the early postpartum period,5 attitudes and management suggestions by
health professionals,6, 7 timing of any obstetric advice,8 any previous infant feeding experience,9
mode of delivery,10 mother–infant separation in the early neonatal period,11 and patterns of
maternal employment soon after the infant's birth.12

Most well-nourished mothers successfully breastfeed their infants without need for significant
dietary changes. Nutritional requirements during lactation and specific nutritional concerns are
addressed in this chapter. How the special maternal and infant needs can be met while
encouraging lactation also is discussed.

NUTRITIONAL REQUIREMENTS

Fluid

When a breastfed infant has poor weight gain or is acting fussy and dissatisfied, the mother is
often told to drink more fluids. Dusdieker and co-workers13 found that women consuming an
average of 2000 ml of fluid each day produced an average of 814 ml of milk in 24 hours.
Increasing fluid intake by 25% had no effect on milk production.

Several studies in underdeveloped countries showed a decrease in milk volume in severely

malnourished mothers.14 In these studies, the mothers' milk volume was increased from an
average of 742 ml to 872 ml per day by supplemental food programs providing increased
calories and protein.14

Energy

Estimates of the energy required for milk production vary from 60% to 90% efficiency in
converting maternal kilocalories ingested into the kilocalorie content of breast milk. 15 An average
of 5.2 kg of weight gained during pregnancy is not accounted for by the fetus or other
components, and it is assumed that some of this weight gain is used to meet the energy
requirements for subsequent breastfeeding.16 The United States recommended daily allowance
for additional maternal calorie take for breastfeeding is about 500 kcal/day. This is in addition
to estimated basal energy requirements which range from 1700 to 3100 kcal depending on
height, activity level and weight for BMI correction factor (Table 1).17

Historically recommended daily allowances (RDA) have been used for assessment and dietary
planning as the RDA is sufficient to meet the nutrient requirements of about 97% of the healthy
persons in each group listed. Between 1997 and 2011 the Institute of Medicine released the
dietary reference intakes (DRIs) and future changes will be issued on individual nutrients as the
science updates sufficiently. DRIs include the estimated average requirement (EAR) which is
estimated to meet requirements of half the healthy persons in each group listed, the RDAs, the
adequate intake (AI) for nutrients without a RDA, the upper intake level (UL) without causing
harm, the estimated energy requirement (EER) and the acceptable macronutrient distribution
range (AMDR). For the clinician wanting a quick and simplified assessment and planning tool,
Table 1 summarizes some of the RDAs for women aged 19–50.

Recommended dietary allowances for selected nutrients for nonpregnant, pregnant, and lactating
women*

Nutrients
Nonpregnant women Pregnant women Lactating women
Carbohydrate (g/kg/day) 100 135 160
Protein (g/kg/day) 0.66 0.88 1.05
Fat-soluble vitamins
A (μg retinal equivalents) 700 (5000 IU) 750 (5360 IU) 1200 (8571 IU)
D (μg) 15 (400 IU) 15 (400 IU) 15 (400 IU)
E (α-tocopherol equivalents) 15 (30 IU) 15 (30 IU) 19 (38 IU)
Water-soluble vitamins
C (mg) 75 85 120
B1 (mg) 1.1 1.4 1.4
B2 (mg) 1.1 1.4 1.6
Niacin (mg) 14 18 17
Folic acid (μg) 400 600 500
B6 (mg) 1.3 1.9 2.0
B12 (μg) 2 2.2 2.4
Minerals
Calcium (mg) 1000 1000 1000
Magnesium (mg) 320 350–400 310–320
Iron (mg) 18 27 10
Zinc (mg) 8 11 12
*A supplement containing 30–60 mg elemental iron is recommended for all pregnant women and
for the first 2–3 months of lactation.
(Modified from Food and Nutrition Board: Dietary Reference Intakes: Recommended Dietary
Allowances and Adequate Intakes. Institute of Medicine. Reports from 1997-2011 may be
accessed via www.nap.edu )

An evaluation of successful and unsuccessful lactation, as defined by the need to offer

supplemental bottle feedings during the infant's first 2 months of life, found that all of the
mothers who were successfully breastfeeding their infants were eating more than their previous
pre-pregnancy normal volume of food.18 Mothers who were unsuccessful in breastfeeding were
consuming fewer than 2000 kcal/day, and many of them reported that they felt a need to diet.
Whichelow19 concluded that mothers must be informed of their extra caloric requirements during
lactation and that they should be advised to eat more if they are concerned about the adequacy of
their milk supply.

Butte and associates20 also found that successful lactation was compatible with gradual weight
reduction in the mother whose energy intake was less than the current recommendations. They
concluded that maternal ingestion of approximately 2200 kcal/day was adequate for both
appropriate milk production and gradual maternal weight loss.20

Protein

The average protein content of human milk from healthy mothers in one study was 1.09 g/dl
compared with 0.93 g/dl from chronically malnourished mothers.21 Women who are chronically
"moderately" malnourished generally weigh less than 90% of standard parameters of weight for
height, are from underdeveloped countries, or follow strict vegetarian diets, consuming less than
50 g of protein/day.

In some studies in underdeveloped countries, protein supplementation resulted in increased

protein content of human milk and increased daily weight gain of the infant.21 A healthy lactating
mother consuming 1.05 g/kg/day of protein needs no additional dietary protein.

Carbohydrates

Approximately 90% of the carbohydrate in human milk is lactose. The amount of lactose in
human milk is relatively constant at 7.3–7.4 g/dl, and appears to be independent of the maternal
carbohydrate ingestion.22 Because of its constant concentration, lactose is thought to be the
regulating factor in the volume of human milk produced.

Fat

Fat is the major source of calories in human milk. The average fat content is about 52% of total
calories.23 Both human milk and standard infant formulas contain about 3.6 g of fat per 100 ml.
Short-chain fatty acids (up to 16 carbons) may be synthesized in the mammary glands. Maternal
plasma triglycerides are the source of long-chain fatty acids and cholesterol in human milk.24

The recent change in the American diet toward increased intake of vegetable fats rather than
animal fats is reflected in a human milk fatty acid content, with increased long-chain fatty acids
and an increase in linoleic acid.24 Human milk produced by vegetarian mothers also shows high
levels of linoleic acid.25 Manipulation of the maternal diet does not appear to alter the total
cholesterol content of human milk significantly.26 The amount of omega-6 fatty acids and
omega-3 fatty acids in human milk is reflective of the maternal diet, with a higher marine fish
intake resulting in a higher omega-3 fatty acid content.27 Initial benefits of omega-3 fatty acids
focused on cardiovascular effects of improving the lipid profile as well as their anti-
inflammatory properties. Supplementation of the maternal diet with omega-3 fatty acids may be
useful in reducing the prevalence of hypertensive disorders of pregnancy, postpartum depression
and preterm birth. There is good evidence that one of the omega-3 fatty acids, docosahexaenoic
acid (DHA) is necessary for brain and retinal development in pregnancy and the newborn time
period. Nonbreastfed newborn infants should be fed a formula with supplemental DHA. The
current formulas used in the United States Woman Infant Children (WIC) programs include
Similac Advance® made by Abbott laboratories (0.15% of total fat as DHA); Enfamil
Premium® made by Mead Johnson (0.32% of total fat as DHA) and Gerber Good Start® (0.32%
of total fat as DHA). Most formula carried by large discount stores contains about 0.32% of total
fat as DHA. The current literature recommends pregnant and breastfeeding mothers should take
either 4 g of regular fish oil capsules, or 2 g of concentrated fish oil capsules daily. Capsules may
be kept refrigerated or in the freezer to reduce nausea. Alternatively, a supplement containing
200–300 mg daily of DHA may be taken. (Examples are Expecta Lipil 200 mg or Kirkland DHA
240 mg or Nature Made DHA 288 mg). An excellent review of the supplements found free of
mercury and pesticides is found online from ConsumerLab.com/results/omega3.asp.

When a mother is taking inadequate calories so that she is using her own fat stores for milk
production, her milk still contains 3–3.5% fat, but the fatty acid composition resembles the
composition of her fat stores.28, 29 Similarly, total milk fat content is the same when maternal
caloric sources are chiefly protein and carbohydrate. However, milk composition changes and
levels of saturated fatty acids increase as lipids are synthesized from fat stores and are not merely
carried as plasma triglycerides from the portal system to the mammary gland.26, 28 A restricted
maternal diet containing less than 20 g total fat may produce essential fatty acid deficiency in the
infant if supplemental essential fatty acids are not provided.

Vitamins

WATER-SOLUBLE VITAMINS

The vitamin and mineral content of human milk is the standard to which cow's milk and infant
formulas are compared (Table 2). The human milk content of these vitamins may vary and
be related to the maternal diet. The vitamin C content of human milk depends on maternal diet,
and may be five times as high as that of cow's milk.30, 31
Table 2. Approximate nutrient content of mature human milk, cow's milk, and typical standard
infant formula

Nutrient Human milk/100ml† Whole cow's milk/100 g* Standard formula/100 ml†

Kilocalories 65–73 61 67
Protein (g) 0.9–1.2 3.15 1.4
Carbohydrate (g) 6.7–7.9 4.8 7.4–7.6

Fat (g) 3.4–3.9 3.25 3.4–3.7

Fat-soluble vitamins
A (IU) 225 142 202
D (IU) 2.0 42 52
E (IU) 0.4 0.08 1.0–1.3
K (μg) 2.3 3 5.4
Water-soluble vitamins
B1 (μg) 20 46 100
B2 (μg) 40–60 169 150
Niacin (μg) 180 890 676-1050
Folic acid (μg) 8–14 0 10–15
B6 (μg) 9–30 36 40–60
B12 (μg) 0.5–1 0.45 0.17–0.2
C (mg) 10 0 9
Minerals
Calcium (mg) 20–25 113 53
Iron (mg) 0.9 0.03 1.2
Zinc (mg) 1–3 4 0.5–0.7

*Data from US Department of Agriculture, Agricultural Research Service 2005, USDA Nutrient
Database for Standard Reference, Release 18 Nutrient Data Laboratory Home Page
(http.//www.nal.usda.gov/fnic/foodcomp)†Product and human milk analysis: NeoFax® 2010.
Formulas cited are: Enfamil Premium Newborn® and Similac Advance Early Shield®

Infantile beriberi has been reported when a breastfeeding mother consumes a diet chiefly
composed of unfortified, milled grains. Vitamin B1 supplementation provides prompt
resolution.32 Deficiencies of vitamin B2, vitamin B6, niacin, and folic acid usually are not seen in
nursing infants, although supplemental amounts of these vitamins given to malnourished mothers
will increase the levels found in human milk.33 The vitamin C content of human milk can be
raised by dietary supplement, and seasonal variations in vitamin C content are seen.33 Most
healthy mothers consume a diet that meets the recommended daily allowances for water-soluble
vitamins. Malnourished and vegan vegetarian mothers require vitamin B12 supplementation to
prevent megaloblastic anemia in their infants (Table 1 and Table 3).34, 35

Table 3. Recommended supplements for maternal vegetarian diet

Vegetarian diet Supplement

Semi-vegetarian (no Iron sulfate, 300–600 mg/day
red meat)
Ovo-lacto- Iron sulfate 300–600 mg/day, zinc sulfate 225 mg/day
vegetarian (no-flesh)
Lacto-vegetarian (no Iron sulfate 300–600 mg/day and zinc sulfate 225 mg/day, vitamin B1 1.5
flesh or eggs) mg and vitamin B12 10 μg/day, or use prenatal vitamins 1 tablet daily (check
protein intake for adequacy)
Vegan Prenatal vitamin or multivitamin supplement with vitamin B12 and calcium
1000 mg/day (check protein pattern for essential amino acid content)

FAT-SOLUBLE VITAMINS

No deficiency syndromes of vitamins A and E have been reported in healthy, term, breastfed
infants.36 Vitamin E-deficient hemolytic anemia has been reported in premature infants and in
infants with malabsorption syndromes.37 Vitamin E supplementation usually is not recommended
for the term infant. Increases in serum vitamin E levels have been reported in newborns whose
lactating mothers were using vitamin E oil to treat early nipple tenderness.38 Studies of maternal
supplementation have not been performed for significant periods to allow assessment of the
potential for toxicity of excessive supplementation.

Rickets has been reported in breastfed infants, particularly those living in northern climates in
winter, in urban areas, and among nonwhites and vegetarians. Daily maternal dietary
supplementation of about 15 μg (400 IU) of vitamin D can prevent rickets in these infants.39, 40
All breastfed infants should receive 400 IU of oral vitamin D drops daily beginning during the
first 2 months of life. 23

Vitamin K deficiency (hemorrhagic disease of the newborn) is seen primarily in breastfed infants
(or infants receiving formula without supplemental vitamin K) who did not receive vitamin K
after delivery.41 Fortified infant formula usually contains 5.4 μg/dl of vitamin K, whereas breast
milk only contains 2.3 μg/dl of vitamin K (Table 2). Severe deficiency, resulting in massive
intracranial hemorrhage, has been reported in several case reports from Taiwan in older breastfed
infants. These infants usually had a preceding gastroenteritis that affected the bacterial flora and
its ability to synthesize vitamin K.42
Minerals

Sodium, potassium, calcium, phosphorus, magnesium, and iron levels in breast milk are
unaffected by maternal dietary intake.36, 43 There are reports from 1920 to 1940 of malnourished
mothers who nursed and had maternal osteomalacia and tetany.44 There also was one report of
increased sodium content in the milk of a mother with cystic fibrosis who was not nursing but
who gave an expressed milk sample. This finding may not be valid.45 One mother with cystic
fibrosis who was actively breastfeeding her infant did not have increased breast milk sodium
content.46

Iron absorption of breastfed infants appears to be aided by the higher lactose levels in human
milk. Woodruff and associates47 found that breastfed infants had higher serum iron
concentrations after birth, and lower total iron-binding capacity at 3, 6, and 9 months of age.
Breastfed infants appear to use dietary iron more efficiently than bottle-fed infants. 48 Several
authors have reported that iron is absorbed in breastfed term infants in sufficient quantities to
ensure adequate iron intake for the first 6–9 months of life.49, 50 After 6 months of age, as infants
show greater interest in chewing, iron-rich solid foods are recommended in the infant's diet.36

Zinc in human milk is more completely absorbed than that in formula, and breastfed infants have
higher serum and hair zinc levels.51 The improved bioavailability of zinc in breast milk may
prevent clinical zinc deficiency in acrodermatitis enteropathica. 51 Clinical zinc deficiency may be
seen in breastfed premature infants with necrotizing enterocolitis or other disorders with
extensive small bowel resection or unusually high gastrointestinal losses.52 Maternal dietary
supplements usually do not increase breast milk zinc content sufficiently; thus, additional oral or
intravenous zinc must be given to the high-risk infant.36, 52

No relationship between maternal dietary copper and breast milk copper concentration is seen. 36
Like zinc, copper deficiency in breastfed infants usually is confined to those receiving parenteral
nutrition and affected with short gut syndrome or prematurity.

The use of iodized salt in the maternal diet may double the level of iodine in human milk, which
may prevent iodine deficiency.36

Fluoridation of drinking water is not associated with a major increase in maternal milk fluoride
levels.36 Fluoride supplementation, 0.25 mg/day, is recommended for the nursing infant from 6
months to 3 years of age, living in an area with drinking water containing less than 0.3 ppm
fluoride concentration.53 The mean selenium concentration of human milk is 2 μg/100 ml, which
is about twice that of formula and correlates with the protein content of milk.54 There are reports
of selenium toxicity in adults living in areas of seleniferous soil. The symptoms included chronic
dermatitis, fatigue, and dizziness.54 No reports of this syndrome in breastfed infants have been
identified.

ASSESSING ADEQUACY OF BREAST MILK

Individualization is required to determine when supplementation with formula or solid foods is

appropriate. One approach is to compare human milk production with recommended dietary
allowances. Recommended daily allowances estimate nutrition requirements based on metabolic
balance studies to which a generous safety margin has been added. They may overestimate actual
needs. These recommendations do not take into account individual variability and the infant's
ability to adjust physiologic efficiency to food availability.

If human milk contains an average of 69 kcal/dl, a child weighing 5 kg at 2 months would need
an average of 900 ml/day of breast milk to meet the recommended daily allowance. 55 The
average amount of breast milk produced in the second month of lactation in American mothers is
reported to be 500–675 ml/day.13 Because most 2-month-old infants grow well on breast milk
alone, either the recommended daily allowance is overly generous or the methods for estimating
human milk production grossly underestimate the amount produced.

As long as a breastfed infant is growing appropriately, maternal milk is providing adequate

volume, calories, and protein, and the mother's diet is adequate. The World Health Organization
released new international growth charts in April 2006 for children from 0 to 59 months based on
the healthy breastfed infant as the recommended standard. Fewer US children will be considered
underweight using the WHO charts instead of the 2000 CDC growth charts and slower growth of
breastfed vs. formula fed infants during ages 3–18 months is normal.56 The CDC recommends
that health care providers use the WHO growth standards to monitor growth for infants and
children aged 0–2 years of age in the United States. Assessing the adequacy of other nutrients in
the breastfed infant does not vary according to the mode of feeding. A combination of
anthropometric measures and clinical symptoms can be used to assess adequacy. Clinical
symptoms of specific nutritional deficiencies in the infant are listed in Table 4.

Table 4. Clinical signs of nutritional deficiencies in the infant

Nutrient Sign of deficiency

Inadequate fluid or Clinical dehydration, increased serum electrolyte level (particularly sodium),
free water intake hyperbilirubinemia in the newborn period
Inadequate calories Weight and height under 25th centile; sparse, bleached-out hair (flag sign);
and protein decreased mid-upper-arm muscle circumference and triceps skinfold;
decreased serum albumin and protein levels
Essential fatty acid Follicular hyperkeratosis
Vitamin D and Rickets, delayed closing of fontanelle or bossing of skull
calcium
Iron Anemia, pale mucous membranes and skin
Zinc Irritability, perioral or anal dermatitis
Copper Triad of anemia, neutropenia, rickets (often found in infants given goat's
milk or with short gut syndrome)
Vitamin B12 and Megaloblastic anemia, ataxia, neurologic deficits
folic acid
Nutrient Sign of deficiency
Vitamin C Tender, bleeding mucous membranes, rickets (due to interaction with
copper), petechiae
Other B vitamins Deficiencies not seen unless the infant has generalized severe malnutrition

VITAMIN AND MINERAL SUPPLEMENTATION

Except for vitamin D, routine vitamin and mineral supplementation is not necessary for the
healthy, well-nourished breastfeeding mother. Many mothers continue to take their prenatal
vitamins after delivery, which is reasonable until the infant is consuming a variety of solid foods
in addition to human milk. Clinical signs that suggest maternal deficiencies of selected nutrients
are listed in Table 5.

Table 5. Clinical signs of nutritional deficiencies in the mother

Nutrient Sign of deficiency

Kilocalories Weight and height under 90% of standard or triceps skinfold thickness under
90% of standard
Protein Mid-upper-arm circumference 90% of standard; decreased serum protein and
albumin levels; hair brittle, with bleached-out color; skin with areas of
patchy, dark pigmentation; dependent edema (with serum albumin levels less
than 2.5 g/dl)
Essential fatty Follicular hyperkeratosis and xerosis, thickened opaque conjunctiva, and
acids and vitamin Bitot's spots (with vitamin A)
A
Niacin, vitamin B2, Nasolabial seborrhea; cheilosis; angular fissures at corners of month;
and vitamin B12 glossitis; beefy, red painful tongue (especially with B12)
Niacin Shirt-sleeve dermatitis (dark pigmentation in sun-exposed areas)
Vitamin B12 and Macrocytic anemia, symmetrical peripheral neuropathy, absent deep tendon
folic acid reflexes, ataxia

Vitamin B12 and calcium supplementation may be necessary if the mother consumes a vegetarian
diet.33, 34 Women who are undernourished and eating a diet during pregnancy containing less than
70% of the recommended daily allowances may need a multivitamin and mineral supplement. 33,
36

The effects of megavitamin supplementation are unknown. Because increased maternal intake of
vitamin A and vitamin D can substantially increase their content in human milk, prolonged
excessive maternal vitamin A and vitamin D supplementation has the potential for infant
toxicity.23, 36

Excessive vitamin C ingestion in pregnant women has resulted in withdrawal scurvy in their
infants.57 The vitamin C content of human milk increases within 30 minutes of maternal
ingestion.31 Mothers who ingest large doses of vitamin C should taper rather than abruptly stop
its ingestion.

MATERNAL CONSIDERATIONS

Employment

Maternal employment soon after the infant's birth is increasingly common and need not preclude
continued breastfeeding. Frequency of breast emptying while away from the infant varies with
infant age, maternal discomfort and desire to provide human milk for missed feedings, and
availability of facilities for comfortable pumping and appropriate storage of pumped milk. 12, 58
Women are likely to breastfeed longer when provision is made for use of an electric breast pump
in privacy, with adequate facilities for storage of the milk at work.59 Many women substitute one
or more formula feedings for breastfeeding instead of pumping and saving milk while at work.

The nutritional needs of the lactating mother will vary with the frequency of her daily nursing
periods. One or two missed infant feedings a day probably does not substantially alter the
mother's nutritional needs, especially if she is active and has other energy needs. More than two
missed feedings will either proportionally reduce the mother's dietary needs or lengthen the time
it takes for her to use her pregnancy-acquired fat stores.

Vegetarian diet

Many lactating women exclude meats or animal products from their diets. The semi-vegetarian
(who only avoids red meats) and the ovo-lacto-vegetarian (who eats no flesh foods) are at risk
for maternal iron and zinc deficiency.60 The lacto-vegetarian (who also avoids eggs) may be at
additional risk for protein deficiency without careful selection of complementary proteins. 60 The
vegan (who consumes only vegetables, grains, and fruits) is at high risk for maternal and infant
mineral, protein, vitamin D, vitamin B12, and other B vitamin deficiencies.34, 35, 60 Recommended
supplements for lactating mothers who follow vegetarian diets are listed in Table 3.

Megaloblastic anemia with profound neurologic manifestations has been reported in some
infants of vegan mothers. The maternal serum vitamin B12 levels in these cases are marginal to
slightly low.34, 35

The zen macrobiotic diet is nutritionally inadequate in almost all required nutrients. It is
contraindicated for the pregnant or lactating woman.60 Any diet containing high amounts of fiber
and whole grain with excessive dietary phytates may impair absorption of iron, zinc, and
calcium. The maternal intake may appear to be adequate, but clinical symptoms of iron, zinc, and
calcium deficiency in the mother are present.60
The fatty acid content in human milk is altered in vegetarian women whose diet meets the
recommended daily allowance for all other nutrients.61 Long-chain saturated fatty acid levels are
reduced, and levels of polyunsaturated fatty acids are increased.61 The clinical significance of this
effect is unknown.

Diabetes

Mothers with diabetes may breastfeed their infants successfully. Close control of blood glucose
levels during pregnancy produces infants with few hypoglycemic and hypocalcemic episodes in
the neonatal period.62 These infants often are alert and are not likely to have difficulties in
breastfeeding or a need for prolonged intravenous administration of glucose and calcium.

Just as with nondiabetic mothers, attention must be paid to increasing the maternal diet by about
500 calories/day to provide for the energy needs for breast milk production.17 Some of the energy
required may be derived from fat stores developed during pregnancy.

Close monitoring of maternal serum glucose levels is recommended to avoid ketonuria and
ketonemia that may occur during fat store mobilization. Although most mothers with diabetes
experience about a 10% decrease in insulin requirements during lactation, some may require an
increase in insulin dosage.63

Breastfeeding in the immediate postpartum period may be slow to be fully established because
infants of some diabetic mothers are delivered before 40 weeks' gestation. These infants may
have hypoglycemia and hypocalcemia, and they may not have a vigorous suck.64 A breast pump
may be useful to stimulate milk production until the infant can nurse. Because the volume of
milk obtained with a mechanical pump often is less than that after established breastfeeding,
maternal insulin needs may vary during this period.

Gastrointestinal disease

The lactating mother who has gastrointestinal disease resulting in malabsorption may be at risk
for nutritional deficiencies. Moderate nutritional depletion is defined as a score of less than 90%
on standard parameters of nutritional assessment (including weight for height). Severe depletion
is defined as a score of less than 60% of standard parameters.65

Lactating mothers with Crohn's disease, ulcerative colitis, or short gut syndromes (such as
following intestinal bypass surgery) must be evaluated for nutritional deficiencies. Loss of
weight or an increase in diarrhea may precede other clinical symptoms. These mothers are at risk
for decreased absorption of protein, fat and fat-soluble vitamins, and minerals, such as calcium,
magnesium, and zinc.66

The degree of loss may be quantified by analysis of a 24-hour stool collection. The maternal diet
may need to be increased, and some of these women may require chemically defined diets or
even total parenteral nutrition. No large studies exist on breastfeeding while the mother is
receiving total parenteral nutrition. Breastfeeding would be possible with careful attention to
maternal intravenous solution content and nutritional monitoring of the mother and infant.
Phenylketonuria

Many women with classic phenylketonuria (PKU) have reached childbearing age. Many of these
women enter pregnancy with elevated serum phenylalanine levels. Several studies have shown a
direct correlation between maternal serum phenylalanine level and mental retardation in the
otherwise normal fetus, who may or may not have the gene for PKU.67, 68 The current
recommendation is that the mother resume her low-phenylalanine diet, using a special low-
phenylalanine formula (Lofenalac®, Phenyl-Free 2® Mead Johnson Nutrition, Evansville, IN;
Phenex -2® from Abbott Nutrition; or similar formula) to keep her level of phenylalanine, before
and during her pregnancy, less than 5 mg/dl.68

Little information exists as to dietary recommendations during lactation for these woman. The
mother's milk could be tested periodically for phenylalanine content. If it is significantly higher
than the normal range for human milk (29–69 mg/dl), then the maternal phenylalanine intake can
be adjusted to keep the milk phenylalanine content within the normal range. A comprehensive
website on management of phenylketonuria is maintained by the University of Washington PKU
clinic in Seattle, Washington. (depts.washington.edu.pku.resources/essentials.html)

Another group of women with hyperphenylalanemia, not classic PKU, has been identified.69
These women have borderline to normal intelligence and usually are identified by having a
newborn with a transiently positive phenylalanine screen result, a child with unexplained mental
retardation, or a relative with mental retardation or PKU.69 There is a strong positive correlation
between maternal serum phenylalanine level during pregnancy and mental retardation in the
offspring.70 Dietary recommendations for diet during pregnancy and lactation are the same as for
mothers with PKU.

Type I hyperlipoproteinemia

Of the hyperlipidemias, usually only type I results in a marked change in the fat composition of
the milk of the affected lactating mother.71 Few case reports are available on lactation in mothers
with type I hyperlipidemia.71 The fat composition in the milk differs greatly from that in other
women's milk. Plasma lipids cannot be taken up by the mammary gland. This inability results in
replacement of much of the plasma long-chain fatty acids usually present in breast milk by short-
and medium-chain fatty acids synthesized de novo in the mammary gland.70 An unaffected
nursing infant can synthesize some long-chain fatty acids, but linoleic acid and linolenic acid
must be supplied in the infant's diet to prevent essential fatty acid deficiency. 71

Maternal dietary recommendations include maintaining serum lipid levels within normal limits
by following a restricted fat diet, and increasing dietary carbohydrate and protein to provide the
additional calories required for lactation. The infant should be monitored for any signs of
essential fatty acid deficiency, because it is unknown whether the mother's milk will provide
adequate linoleic and linolenic acid.71

Cystic fibrosis
Case reports are available on lactation in the mother with cystic fibrosis. One brief report
described a 20-year-old woman whose breastfed infant was growing and thriving at 15 weeks
after delivery. The mother was unable to maintain her prepartum weight, and her pulmonary
status worsened. The sodium content of the breast milk did not differ significantly from the mean
values for human milk. The total fat, immunoglobulin (Ig) G, and IgM levels were low, however,
and the total protein and IgA levels were elevated. No pathogens were cultured from the milk. 46
The number of mothers with cystic fibrosis that are breastfeeding is increasing and a current
website (cysticfibrosis.about.com/od/pregnancyandcf/a/breastfeed.htm) is a good resource for
these mothers.

INFANT CONSIDERATIONS

Prematurity

The nutritional needs of the preterm infant differ from those of the term infant and the
immaturity of these infants may cause problems such as malabsorption, poor suck and swallow
reflexes, and necrotizing enterocolitis.72

The estimated in utero accretion requirements for sodium, potassium, chloride, protein, vitamin
D, calcium, phosphorus, and potassium may not always be met by human milk alone. In the
infant less than 32 weeks gestation or weighing less than 1500 g, current recommendations are to
supplement human milk with a fortifier designed for premature infants.73 Commercially available
breast milk fortifiers (Enfamil® Human Milk Fortifier (Mead Johnson Nutrition) and Similac®
Human Milk Fortifier (Abbott Laboratories) are available to add to breast milk to increase the
caloric content from 20 kcal per ounce to 22 or 24 kcal per ounce as well as supply additional
vitamins and minerals.

Other advantages of using human milk for the premature infant are a decrease in necrotizing
enterocolitis, decreased diarrhea, increased gastric emptying and reduced antibiotic usage. 74 The
amount of breast milk produced may not be adequate because of the infant's poor suck reflex,
infrequent breast stimulation by the infant, and maternal anxiety about the infant. 72 Frequent,
consistent pumping or hand expression may be useful in maintaining the maternal milk supply. It
is recommended the mother pump at least every 3 hours during the daytime and at least every 5
hours at night. Pumped milk should be obtained in a sanitary manner and immediately
refrigerated or frozen. Refrigerated human milk should be used within 48 hours (24 if mixed
with fortifier). Frozen milk can be stored in a home freezer for 3 months and should be used
within 24 hours of being thawed. Frozen milk should be thawed in the refrigerator, or under
running warm water, but never microwaved. Nonfortified human milk may be used exclusively
when the infant reaches term size or after 36 weeks' gestation. Metoclopramide 10 mg orally
every 8 hours may increase milk production.75 It also increases prolactin levels through a
dopamine antagonist mechanism.

Milk produced by mothers of premature infants in the first few weeks after birth differs from the
milk they produce later and from the milk produced by mothers of term infants.76 The initial milk
of mothers of premature infants born before 31 weeks' gestation is usually higher in protein,
sodium, fatty acids, and energy.77
The well-nourished mother of a premature infant should follow a dietary plan based on
recommended dietary allowances for lactation. Maternal anxiety may be high, and additional
emotional support often is needed. With time, practice, and emotional support, mothers of
premature infants often provide for most, if not all, of their infant's nutritional needs.

Multiple births

Successful breastfeeding of twins or triplets is possible. The maternal diet should be increased by
at least 800 calories/day, and continuation of prenatal vitamins or multivitamins is advised. 17
Mothers of twins or triplets who do not ingest sufficient calories for the extra energy needed for
milk production may have increased mobilization of endogenous fat stores and earlier return to
prepregnancy weight.78

Many twins or triplets are born prematurely and spend time in the newborn intensive care unit. In
addition to information and support, breast pumping is recommended to stimulate and maintain
milk production until the infants can use some or all of the mother's milk.

Food allergies

Heredity plays an important role in food allergies and atopic disease. Either skin manifestations
of atopia or gastrointestinal symptoms may be related to food allergies. Several studies have
attempted to evaluate the prevention of development of infant atopia and gastrointestinal
disturbances by manipulating the maternal diet during pregnancy and lactation to avoid
allergenic foods and by feeding the infant either breast or soy milk.79 Many of these studies were
not well designed and did not control for duration of exclusive breastfeeding.

Other studies suggested a decrease in the infant's gastrointestinal symptoms with a maternal diet
devoid of cow's milk and egg proteins. Cow's milk, goat's milk, soy milk, and egg proteins in the
maternal diet are secreted into the breast milk.80, 81, 82 Jacobsson and colleagues83 reported high
levels of β-lactoglobulin in the milk of mothers whose infants had colic. After cow's milk was
removed from the diet, the β-lactoglobulin levels were not detectable, and the colic resolved.

In addition to allergic problems with protein components of cow's milk, lactose intolerance in the
mother is prevalent worldwide.84 More than 80% of Oriental and Eskimo adults and 60–80% of
Native Americans, blacks, and Hispanics are lactose intolerant.84 Alternative sources of calcium,
such as calcium-rich vegetables and supplemental calcium tablets, are recommended in the
maternal diet during pregnancy and lactation.

Current recommendations have changed from recommending restrictions in the maternal diet to
not recommending any maternal dietary restrictions in pregnancy or lactation. There remains
some evidence that breastfeeding for the first 4 months of life in comparison to cow milk protein
decreases risk of atopy in high risk children.84 If there is not a strong family history of soy
allergy, soy protein products may be used in the maternal diet during pregnancy and lactation. 85

There is modest benefit of use of a casein hydrolysate or a partially hydrolyzed whey protein
formula in the high risk infant not breastfed. Examples of casein hydrolysate formulas
are: Nutramigen® or Pregestimil® (Mead Johnson Nutrition). Good Start® (Gerber) contains
partially hydrolyzed whey protein.86

Cleft palate

It is difficult to feed the baby with a significant cleft palate exclusively at the breast. One strategy
is to use a breast pump and then feed the infant using a cleft palate nurser. There are several
organizations, such as the Cleft Palate Foundation that have websites with instructions as well as
on-line support groups. The recommendation would be for the mother to consult a lactation or
dysphagia specialist as ease of breastfeeding would vary according to the individual infant's
anatomic defect.

Inborn errors of metabolism

PHENYLKETONURIA

Phenylketonuria is a common inborn error of metabolism, occurring in 1:10,000 white children.87

Breastfeeding often was discouraged in the past, and the infant was fed a combination of a small,
measured amount of standard formula and a special formula containing low levels of
phenylalanine.88 Human milk averages 41 mg/dl phenylalanine, compared with 75 mg/dl in
standard infant formulas and 159 mg/dl in cow's milk.88 With close monitoring, breastfeeding
may be continued for the infant with PKU.

A comprehensive website from the University of Washington, Seattle, Washington describes

protocols for feeding, information for both parents and professionals, recipes and contact
information (depts.washington.edu.pku.resources/essentials.html). When the mother wants to
breastfeed, several strategies may be used. They include weighing the infant before and after
feeding to determine amount of breast milk ingested, offering a low phenylalanine formula after
a certain number of minutes at the breast, checking daily blood levels of phenylalanine until the
infant's level is stable, substituting low phenylalanine formula for one or two feedings a day and
pumping milk at the feeding time to maintain the maternal milk supply, and placing low
phenylalanine formula in a nursing supplementer. The supplementer allows the infant to nurse
and receive the low phenylalanine formula simultaneously. The optimal blood level of serum
phenylalanine that maintains adequate infant growth is less than 5 mg/dl for the first 6 months of
life.88

Other than following the recommended daily allowances for lactation, no alteration in maternal
diet is necessary for nursing an infant with PKU. Restricting the intake of maternal dietary
protein does not lower the phenylalanine content of breast milk.

TYPE I HYPERLIPOPROTEINEMIA

This rare metabolic defect is associated with a defect of lipoprotein lipase activity. This defect
results in an inability to clear any dietary fat, and levels of serum chylomicrons and serum
triglycerides can be as high as 10,000 mg/dl.23
The average fat content of 24-hour pooled milk samples varies from 2.10 to 3.33%.26, 28 At 3% fat
content, the infant could be fed a maximum of 660 ml or 22 oz of human milk each day if a
dietary fat restriction of 20 g daily was desired. The remainder of the intake would need to come
from a nonfat formula. Each infant must be managed on an individual basis, depending on the fat
content of the mother's milk and the feeding technique. The infant could be allowed to nurse for
a specific period, and triglyceride levels could be obtained frequently, with nursing time adjusted
accordingly. Another alternative, although cumbersome, is to pump the breast and give a
measured amount of human milk fortified with nonfat dry milk and another carbohydrate source,
or one of the commercially available products low in fat (Abbott® Nutrition or Mead Johnson
Nutrition®) to the infant in a bottle. The infant requires careful monitoring for any symptoms of
linoleic acid deficiency.

OTHER INBORN ERRORS OF METABOLISM

There are over 20 specialty infant formulas for inborn errors of metabolism. They are designed
for infants with hypercalcemia, urea cycle disorders, homocystinuria, hypermethionemia, maple
syrup urine disease, propionic or methylmalonic acidemia, glycogen storage disorders, need for a
ketogenic diet or cholestasis, chylothorax and other disorders. With some of these a measured
quantity of human milk may be used under supervision of a pediatric specialist in this area. More
detailed information can be obtained from the websites of Abbott Nutrition or Mead Johnson
Nutrition.

CYSTIC FIBROSIS

Cystic fibrosis is a common inherited enzyme defect, occurring in 1:1500 to 1:2000 live, white
births. Eighty-five per cent of affected infants have some pancreatic impairment. Regardless of
the feeding method, these infants usually need supplemental fat-soluble vitamins (aqueous
preparations of vitamins A, E, D, and K) and exogenous pancreatic enzymes.23 Maternal diet
does not need to be modified in the unaffected mother wanting to nurse an infant with cystic
fibrosis.

Drugs and chemicals in breast milk

To alter the practice of weaning as a precaution during drug therapy, information must be
available to permit accurate evaluation of the risks and benefits of therapy to the mother and
infant. Older studies often were contradictory, with most human data including only a small
number of subjects or a single case report. Single determinations of a drug in breast milk are of
limited value. Only within the last 10 years have sound pharmacokinetic principles been applied
to drug or chemical excretion in human breast milk. Most drugs in breast milk are found in
concentrations equal to or lower than maternal plasma levels.

Many important drugs have not been studied adequately, and information regarding their short-
or long-term effects in infants often is lacking. When publishing data, manufacturers sometimes
use such words as may or might when referring to the possible effect of the drug on the nursing
infant. Often, these words are understood to mean that the drug is contraindicated in nursing
mothers. Neonatal effects are thought to be negligible with antibiotic exposure, except for
allergic sensitization, candidal infection, or diarrhea. Cardiovascular drugs often do not cause
adverse effects on the newborn at maternal therapeutic doses, but product information on newer
medications should always be checked. Gastrointestinal drugs may cause diarrhea or colic.
Effects from exposure to psychoactive substances in breast milk are unknown, but may be of
concern. Long-term antihistamine use may cause sedation or decreased feeding. Concentrations
of hormones and synthetic substances such as thyroid preparations are thought to be too small to
be clinically significant. Information about specific drugs may be found in standard textbooks or
on-line sites.89, 90 The United States National Library of Medicine has a toxicology data network
with a subsection on drugs and lactation – LactMed (TOXNET.NLM.NIH.GOV). A mobile
application is available from Texas Tech University Health Sciences Center, Infant Risk Center
Mobile App, www.infantrisk.com.

Volatile oils, such as in garlic, onion, and melons, may be poorly tolerated by the infant.60
Artificial colors and dyes used in beverages, gelatin desserts, and other foods can color the
milk.91 Lawrence60 reported cases of green milk caused by a sports drink colored with food dye,
kelp, seaweed, and colored vitamin tablets. Such color changes do not affect the nutritional
content of the milk. Excessive maternal consumption of caffeine and methylxanthines (several
cups of coffee or tea each day) causes hyperstimulation in the nursing infant.92 Herbal teas may
contain natural coumarins or other potent pharmacologic and psychogenic compounds that could
cause bleeding or other problems.93 It is not known whether significant amounts of these
compounds are secreted into human milk in women who drink herbal teas regularly.

Women with a high exposure to agricultural chemicals, such as polychlorinated biphenyl (PCB),
may have blood levels 10–100 times those of nonexposed mothers.94 Detectable levels in their
milk usually are lower than the levels found in cow's milk. The breastfed infants of these mothers
have PCB residue in the blood. Levels in the infant relate directly to the duration of
breastfeeding rather than to maternal serum PCB concentration.94 No significant medical
problems in these infants have been seen, and no infants were diagnosed with chronic PCB
poisoning. Testing of human milk for PCB content is not required or recommended unless there
has been an unusually high exposure or the area has been designated by the state health
department as heavily contaminated.

POTENTIAL CONTRAINDICATIONS TO BREASTFEEDING

Often, questions are asked about the suitability of breast milk in meeting the infant's nutritional
needs under a variety of infant and maternal conditions. The following situations may result in
temporary or complete discontinuation of breastfeeding.

Cancer of the breast

If breastfeeding means that the mother may delay definitive treatment, it is not recommended. A
positive family history for breast cancer is not a contraindication to breastfeeding. 95

Other cancer
During chemotherapy, other than that with prednisone, the mother's milk may be pumped and
discarded for the duration of chemotherapy. Breastfeeding can be resumed after drug levels no
longer are found in the milk, or until the time since the last dose exceeds four half-lives of the
drug.

Tuberculosis

Sputum-positive tuberculosis is a contraindication to breastfeeding until the mother is under

effective treatment for at least 1 week and the infant is receiving isoniazid prophylaxis. 96 Milk
may be pumped and discarded until this time.

Hepatitis B and C

Hepatitis B can be transmitted to the infant transplacentally during pregnancy, by the fecal–oral
route during delivery, and through breast milk.96, 97, 98 For mothers who have active hepatitis B
during pregnancy the American Academy of Pediatrics Committee on Infectious Disease has
taken the position that “breastfeeding should be avoided if artificial milk formulas and adequate
refrigeration facilities are available. However, breastfeeding is indicated for infants living in
areas of the world where hepatitis, type B, infection is highly endemic and artificial formulas and
refrigeration are not available.”96

Other authors have not found hepatitis B in unconcentrated breast milk specimens from women
who were carriers but were not actively infected.97, 98 Krugman99 noted that the use of vaccines
against viral hepatitis so substantially reduced its incidence that the risk associated with
breastfeeding by carrier mothers may be significantly less than previously thought. The
American Academy of Pediatrics does not consider breastfeeding contraindicated in mothers
infected with hepatitis C antibody or hepatitis C virus-RNA-positive blood.2

Herpes simplex

Fatal newborn cases of herpes simplex type 1 and herpes simplex type 2 involving maternal
breast lesions have been reported.96, 100, 101 If suspicious breast lesions are present, the mother
should empty her breasts and discard the milk until lesions have resolved.

Acquired immune deficiency syndrome

Case studies report possible transmission of acquired immune deficiency syndrome retrovirus
through human milk.102, 103 Women in high-risk groups (e.g., intravenous drug abusers, those born
in areas of high incidence of heterosexual transmission, those who have been sexual partners of
affected men) should be excluded from donating human milk. Seropositive women should be
advised against breastfeeding their newborns in areas of the world where alternate, adequate food
source is available and affordable for the infant.96

Radioactive drugs
Interruption of breastfeeding is necessary during exposure to diagnostic radioactive isotopes.
Milk should be pumped and discarded during the first four half-lives of the drug. For sodium
pertechnetate technetium-99m, iodohippurate sodium iodine-131, and similar compounds, the
infant should be fed immediately before the administration of the radionuclide. The next three
milk fractions should be discarded before nursing is resumed.104 Only the first milk fraction after
radionuclide administration should be discarded for red blood cell labeled (technetium-99m),
petetic acid (technetium-99m), methylene diphosphonate (technetium-99m), and edetic acid
(chromium-57).104, 105

When radionuclide compounds are used for treatment, breast milk also should be discarded for
four half-lives. For iodine-131, discarding milk for four half-lives (half-life of 8 days) causes a 4-
week interruption of breastfeeding.106

Oral contraceptives

The advisability of recommending oral contraceptives to lactating women continues to be

debated, both for their maternal and infant effects. Lonnerdal and associates107 reported
significant differences in some protein components of human milk and a decrease in total volume
among women taking oral contraceptives compared with women not using oral contraceptives. 108
However, even with these differences, nutrient composition of the breast milk was within normal
limits, and no infants had clinical signs or nutritional deficiencies.

Stefan and Nygren108 reported that concentrations of ethinyl estradiol in breast milk obtained
from women taking oral contraceptives were approximately 1% of the dose taken. They
estimated that an oral contraceptive containing 50 μg of ethinyl estradiol excretes 10 ng of
ethinyl estradiol per 600 ml breast milk expressed. Today, most oral contraceptives have 30 µg
or less of ethinyl estradiol or equivalent.

Roepke and Kirksey109 found that women who took oral contraceptives for longer than 30
months before their pregnancy had substantially reduced reserves of vitamin B6 during
pregnancy and lactation. Some authors suggest that supplemental vitamin B6 be given during
pregnancy to women with a history of long-term use of oral contraceptives.109

Infant galactosemia

Galactosemia is an absolute contraindication to breastfeeding because the chief carbohydrate

source in milk is lactose. Galactosemia occurs in only 1:60,000 live births.110 Use of human or
cow's milk or other products containing lactose will result in hepatomegaly, jaundice, cataract
formation, and mental retardation in the infant. Meat base or casein hydrolysate formulas are
used to meet nutritional requirements.53

CONCLUSIONS

Most women who deliver an infant have adequate nutritional stores for breastfeeding. The
maternal diet can influence the nutrient content of breast milk, particularly the volume of milk
produced, its protein content, its water-soluble vitamin content, and its fatty acid composition.
Vitamin and mineral supplementation of the maternal diet may not be necessary, except for the
strict vegetarian or malnourished mother. Many physicians recommend the nursing mother
continue her prenatal vitamins while lactating since the quality of the maternal diet may not be
easy to ascertain. Special situations, such as diabetes, gastrointestinal problems, and inborn
errors of metabolism, do not preclude breastfeeding if recommended adjustments to the maternal
diet are made. The nutritional needs of infants weighing less than 1500 g or infants with special
problems may be partially or fully met by breastfeeding. Specific adjustments to the maternal or
infant diet may be required.

Many chemicals and drugs are excreted into breast milk. Seldom is breastfeeding contraindicated
because of drugs or environmental contaminants, although an awareness of potential effects may
make the mother avoid unnecessary exposure to these substances. Breastfeeding may have to be
suspended temporarily when certain radionuclides are used for diagnosis or treatment, or while
the mother is receiving chemotherapy. Afterward, it may be resumed.

Infectious agents, such as those of hepatitis, herpes, tuberculosis, or acquired immune deficiency
syndrome, may be transmitted to the infant through breast milk. Temporary or permanent
cessation of breastfeeding may be recommended. The only absolute contraindication to
breastfeeding is galactosemia in the infant.

Special maternal or infant needs requiring dietary changes on either part sometimes are used as
reasons to discourage breastfeeding. For a motivated mother who wants to nurse her infant, the
specific recommendations in this chapter are designed to help her to provide for both her own
and her infant's nutritional needs. These recommendations are intended to be used to promote
rather than discourage breastfeeding.

Topic 6: malnourished people

Malnutrition is a serious condition that happens when your diet does not contain the right
amount of nutrients.

It means "poor nutrition" and can refer to:

 undernutrition – not getting enough nutrients

 overnutrition – getting more nutrients than needed

These pages focus on undernutrition. Read about obesity for more about the problems associated
with overnutrition.

Signs and symptoms of malnutrition

Common signs of malnutrition include:

 unintentional weight loss – losing 5% to 10% or more of weight over 3 to 6 months is one of the
main signs of malnutrition
  a low body weight – people with a body mass index (BMI) under 18.5 are at risk of being
malnourished (use the BMI calculator to work out your BMI)
 a lack of interest in eating and drinking
 feeling tired all the time
 feeling weak
 getting ill often and taking a long time to recover
 in children, not growing or not putting on weight at the expected rate

Risks of malnutrition

Malnutrition is a common problem that affects millions of people in the UK.

Anyone can become malnourished, but it's more common in people who:

 have a long-term health conditions that affect appetite, weight and/or how well nutrients are
absorbed by the gut, such as Crohn's disease
 have problems swallowing (dysphagia)
 are socially isolated, have limited mobility, or a low income
 need extra energy, such as people with cystic fibrosis, are recovering from a serious injury or
burns, and those with tremors (uncontrollable shaking)

People who are 65 years and over are particularly at risk, and weight loss is not an inevitable
result of old age.

Treatments for malnutrition

Treatment for malnutrition depends on your general health and how severely malnourished you
are.

The first dietary advice is usually to:

 eat "fortified" foods that are high in calories and protein

 snack between meals
 have drinks that contain lots of calories

Some people also need support with underlying issues such as limited mobility. For
example, care at home or occupational therapy.

If a child is malnourished, their family or carers may need advice and support to address the
underlying reasons why it happened.

If these initial dietary changes are not enough, a doctor, nurse or dietitian may also suggest you
take extra nutrients in the form of nutritional drinks or supplements.

If you have difficulty eating and this cannot be managed by making changes such as eating soft
or liquid foods, other treatments may be recommended, such as:
  a feeding tube – this can be either passed down your nose and into your stomach, or inserted
directly into your stomach through the skin of the tummy
 nutrition that's given directly into a vein

Preventing malnutrition

The best way to prevent malnutrition is to eat a healthy, balanced diet.

You need to eat a variety of foods from the main food groups, including:

 plenty of fruit and vegetables

 plenty of starchy foods such as bread, rice, potatoes, pasta
 some milk and dairy foods or non-dairy alternatives
 some sources of protein, such as meat, fish, eggs and beans

The Eatwell Guide has more information about the types of food you should include in your diet
and how to get the right balance between them all.

Speak to a GP or specialist if you have a health problem that puts you at increased risk of
malnutrition. You may have more complex dietary needs or need to take supplements.

REFERENCES
1 Breastfeeding: Data: Report Card- Results from the 2008 National Immunization Survey.
U>S> Department of Health and Human Services Centers for Disease Control and
Prevention. Available online at http://www.cdc.gov/breastfeeding/data
2 American Academy of Pediatrics: Policy Statement. Breastfeeding and the use of human
milk. Pediatrics Vol. 115 No. 2 February 2005 496-506
Topic 4: Infant and young child Nutrition
Key facts

 Every infant and child has the right to good nutrition according to the "Convention on the Rights
of the Child".
 Undernutrition is associated with 45% of child deaths.
 Globally in 2020, 149 million children under 5 were estimated to be stunted (too short for age),
45 million were estimated to be wasted (too thin for height), and 38.9 million were overweight
or obese.
 About 44% of infants 0–6 months old are exclusively breastfed.
 Few children receive nutritionally adequate and safe complementary foods; in many countries
less than a fourth of infants 6–23 months of age meet the criteria of dietary diversity and
feeding frequency that are appropriate for their age.
 Over 820 000 children's lives could be saved every year among children under 5 years, if all
children 0–23 months were optimally breastfed. Breastfeeding improves IQ, school attendance,
and is associated with higher income in adult life. (1)
 Improving child development and reducing health costs through breastfeeding results in
economic gains for individual families as well as at the national level.
Undernutrition is estimated to be associated with 2.7 million child deaths annually or 45% of all child
deaths. Infant and young child feeding is a key area to improve child survival and promote healthy
growth and development. The first 2 years of a child’s life are particularly important, as optimal nutrition
during this period lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better
development overall.

Optimal breastfeeding is so critical that it could save the lives of over 820 000 children under the
age of 5 years each year.

WHO and UNICEF recommend:

 early initiation of breastfeeding within 1 hour of birth;

 exclusive breastfeeding for the first 6 months of life; and
 introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months
together with continued breastfeeding up to 2 years of age or beyond.

However, many infants and children do not receive optimal feeding. For example, only about
44% of infants aged 0–6 months worldwide were exclusively breastfed over the period of 2015-
2020.

Recommendations have been refined to also address the needs for infants born to HIV-infected
mothers. Antiretroviral drugs now allow these children to exclusively breastfeed until they are 6
months old and continue breastfeeding until at least 12 months of age with a significantly
reduced risk of HIV transmission.

Breastfeeding

Exclusive breastfeeding for 6 months has many benefits for the infant and mother. Chief among
these is protection against gastrointestinal infections which is observed not only in developing
but also industrialized countries. Early initiation of breastfeeding, within 1 hour of birth, protects
the newborn from acquiring infections and reduces newborn mortality. The risk of mortality due
to diarrhoea and other infections can increase in infants who are either partially breastfed or not
breastfed at all.

Breast-milk is also an important source of energy and nutrients in children aged 6–23 months. It
can provide half or more of a child’s energy needs between the ages of 6 and 12 months, and one
third of energy needs between 12 and 24 months. Breast milk is also a critical source of energy
and nutrients during illness, and reduces mortality among children who are malnourished.

Children and adolescents who were breastfed as babies are less likely to be overweight or obese.
Additionally, they perform better on intelligence tests and have higher school attendance.
Breastfeeding is associated with higher income in adult life. Improving child development and
reducing health costs results in economic gains for individual families as well as at the national
level.
Longer durations of breastfeeding also contribute to the health and well-being of mothers: it
reduces the risk of ovarian and breast cancer and helps space pregnancies–exclusive
breastfeeding of babies under 6 months has a hormonal effect which often induces a lack of
menstruation. This is a natural (though not fail-safe) method of birth control known as the
Lactation Amenorrhoea Method.

Mothers and families need to be supported for their children to be optimally breastfed. Actions
that help protect, promote and support breastfeeding include:

 adoption of policies such as the International Labour Organization’s "Maternity Protection

Convention 183" and "Recommendation No. 191", which complements "Convention No. 183" by
suggesting a longer duration of leave and higher benefits;
 adoption of the "International Code of Marketing of Breast-milk Substitutes" and subsequent
relevant World Health Assembly resolutions;
 implementation of the "Ten Steps to Successful Breastfeeding" specified in the Baby-Friendly
Hospital Initiative, including:
o skin-to-skin contact between mother and baby immediately after birth and initiation of
breastfeeding within the first hour of life;
o breastfeeding on demand (that is, as often as the child wants, day and night);
o rooming-in (allowing mothers and infants to remain together 24 hours a day);
o not giving babies additional food or drink, even water, unless medically necessary;
 provision of supportive health services with infant and young child feeding counselling during all
contacts with caregivers and young children, such as during antenatal and postnatal care, well-
child and sick child visits, and immunization; and
 community support, including mother support groups and community-based health promotion
and education activities.

Breastfeeding practices are highly responsive to supportive interventions, and the prevalence of
exclusive and continued breastfeeding can be improved over the course of a few years.

Complementary feeding

Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is
provided by breast milk, and complementary foods are necessary to meet those needs. An infant
of this age is also developmentally ready for other foods. If complementary foods are not
introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth
may falter. Guiding principles for appropriate complementary feeding are:

 continue frequent, on-demand breastfeeding until 2 years of age or beyond;

 practise responsive feeding (for example, feed infants directly and assist older children. Feed
slowly and patiently, encourage them to eat but do not force them, talk to the child and
maintain eye contact);
 practise good hygiene and proper food handling;
 start at 6 months with small amounts of food and increase gradually as the child gets older;
 gradually increase food consistency and variety;
  increase the number of times that the child is fed: 2–3 meals per day for infants 6–8 months of
age and 3–4 meals per day for infants 9–23 months of age, with 1–2 additional snacks as
required;
 use fortified complementary foods or vitamin-mineral supplements as needed; and
 during illness, increase fluid intake including more breastfeeding, and offer soft, favourite foods.

Feeding in exceptionally difficult circumstances

Families and children in difficult circumstances require special attention and practical support.
Wherever possible, mothers and babies should remain together and get the support they need to
exercise the most appropriate feeding option available. Breastfeeding remains the preferred mode
of infant feeding in almost all difficult situations, for instance:

 low-birth-weight or premature infants;

 mothers living with HIV in settings where mortality due to diarrhoea, pneumonia and
malnutrition remain prevalent;
 adolescent mothers;
 infants and young children who are malnourished; and
 families suffering the consequences of complex emergencies.

HIV and infant feeding

Breastfeeding, and especially early and exclusive breastfeeding, is one of the most significant
ways to improve infant survival rates. While HIV can pass from a mother to her child during
pregnancy, labour or delivery, and also through breast-milk, the evidence on HIV and infant
feeding shows that giving antiretroviral treatment (ART) to mothers living with HIV
significantly reduces the risk of transmission through breastfeeding and also improves her health.

WHO now recommends that all people living with HIV, including pregnant women and lactating
mothers living with HIV, take ART for life from when they first learn their infection status.

Mothers living in settings where morbidity and mortality due to diarrhoea, pneumonia and
malnutrition are prevalent and national health authorities endorse breastfeeding should
exclusively breastfeed their babies for 6 months, then introduce appropriate complementary
foods and continue breastfeeding up to at least the child’s first birthday.

Helpful hints for feeding your baby

These are some helpful hints for feeding your baby:

 Breast milk is best for your baby and is beneficial even if you only breastfeed for a short
amount of time, or part-time.
 Cow’s milk-based infant formula with iron should be offered as the first choice of
formula if you do not breastfeed.
 Keep your baby on breast milk or infant formula until they are 1-year-old.
  Start solid foods when your baby can hold up their head, sit-up with support, and no
longer has tongue thrusting (4 to 6 months).
 When starting solids, start with rice cereal mixed with breast milk or formula on a spoon.
Do not give solids in the bottle or with an infant feeder.
 Once your baby is tolerating cereal, offer vegetables, then add fruits, and then meats.
 Ask your baby’s healthcare provider about the best way to add new foods to your baby’s
diet.
 Progress in the texture of foods so that your baby is eating table foods by their first
birthday.
 Don't give these foods to your baby during the first year of life:
o Honey
o Foods that can be easily choked on (like hot dogs, peanuts, grapes, raisins, or
popcorn)
 Unless your baby is known to have or has severe allergies (for instance, breaking out in
hives, vomiting, or having trouble breathing), recent reports and studies have shown that
introducing whole eggs and peanut butter at a young age—even at 4 to 6 months—
reduces the chance of your baby developing allergies to these foods. Talk to your
baby’s healthcare provider about whether these foods are appropriate for your baby.

Nutritional needs of pre-school children

Through parental education, the practice nurse plays an important role in ensuring the nutritional
needs of children are adequately met, writes Ruth Taylor
Nutrition in children of all ages is instrumental for healthy
development in all areas of living physical, psychological and social
well-being. A diet inadequate in nutrient dense foods may result in
delayed development, psychomotor delay and behavioural disorders.
These are all preventable by educating parents and families about basic
nutrition.

Nutrition can be defined as what foods the individual consumes and

how the body uses them.

Young children should not be regarded as young adults. As they are

still growing, in order to achieve satisfactory growth children require
larger amounts of nutrients per unit of body weight than adults. Therefore, when children are fed
foods which contain inadequate amounts of nutrients, they may fail to grow and develop
adequately.1 Lack of adequate nutrition will cause failure to gain weight in the short term and in
the longer term will result in small stature.

Energy

Energy requirements for pre-school children increase as the child grows older:
  A one year old girl requires 1,165 kcal/day
 A one year boy needs 1,230 kcal/day
 A four year old girl requires 1,545 kcal/day
 A four year a boy needs 1,715 kcal/day.2

Fats

A low fat diet for children can result in insufficient energy. Fat is a concentrated source of
energy, fat soluble vitamins and essential fatty acids. Fats also make food more palatable. A diet
with adequate amounts of fat enables children to take in energy in a limited volume of food as
they have small stomachs and cannot eat large volumes. It is necessary to educate parents
particularly that low fat milks and foods are not suitable for young children.

Fibre

Fibre foods are bulky and young children with small appetites who are offered a diet high in
fibre, may not ingest adequate energy. Phytate, a substance associated with cereal fibre, can bind
with and prevent the efficient absorption of certain minerals such as calcium, phosphorus, iron,
copper and zinc.1 Children who may be eating sufficient amounts of these minerals but are
consuming too much fibre, may actually become deficient in these minerals.

Dietary fibre should be encouraged but not excessively so in small children. Wholemeal bread,
wholemeal breakfast cereals, pulse vegetables, fruit and vegetables all should be encouraged,
particularly as the child gets older.

Protein

Protein intake ranges from 14.5g/day in 1-3 year olds up to 19.7g/day in 4-6 year olds.2 All pre-
school children should have adequate intake of protein and they can eat meat, dairy produce,
eggs, chicken and fish to meet their protein needs.

Iron

Iron intakes in children have been shown to be low3 and many pre-school children have been
found to be anaemic.4 A study carried out in a general practice setting in 1995 found that 36% of
one year olds were anaemic. Following the introduction of education programmes for mothers by
primary care professionals, one year later it was found that the percentage of anaemic children
had decreased to 24% of 122 children screened at 14 months.4 The practice nurse can educate
parents with regard to increasing iron in the diet through iron rich foods such as red meat, liver,
fortified cereals and green vegetables. Vitamin C increases the absorption of iron from food and
a small drink of juice should be offered at mealtimes.

Carbohydrates

Carbohydrates are an important source of energy. Starchy foods such as pasta, bread and rice
should be plentiful in the diet. Payne in 1991 found that the main source of sugar in the diet of
pre-school children was pure fruit juices and blackcurrant syrups.5 There are strong links
between sugar intake and the incidence of dental caries, particularly in pre-school children. To
minimise the risks, parents should be encouraged to discontinue the use of feeding bottles after
the age of one and to encourage the use of feeding cups. Also, frequent consumption of sugary
drinks, sweets and snacks should be discouraged as these influence the child's appetite.

Fluid

Fluid intake is a matter of concern in pre-school children. A study carried out in 1995
demonstrated that squash was the most popular drink, with milk coming in second. Plain water
was much lower in popularity.6 The authors suggest that children as young as two become
conditioned to the sweet taste of squash so that they refuse to drink water. Children with a high
intake of squash may have a diminished appetite and as a result miss out on valuable nutrients at
meal times. Again, a high intake of squash will affect children's dentition.

Problems with nutrition in pre-school children

Phases of eating patterns are common in the pre-school years. There may be an obvious cause
such as illness or the arrival of a sibling, but phases or fads usually reflect the child's developing
independence and the need to assert individuality.

Family attitudes can affect the child's eating habits and behaviour. Food and eating is a learning
experience for children and also can be a source of frustration and the cause of many arguments
between parents. However, healthy children will not starve themselves and usually what isn't
consumed at one meal will be made up for at the next.

A 1991 study found that while food consumption from meal to meal was highly erratic, total
daily energy intakes were relatively constant.7 Excessive milk intake (greater than 1.5 pints per
day) can diminish the appetite and as a result the child may not eat properly at mealtimes.

Faddy eating is part of normal development and the less said about it to the child and at meal
times, the better. New foods and tastes should be introduced frequently with presentation of food
also being important. Three main meals should be encouraged with tooth-friendly snacks
between meals.

It is important that parents encourage dental health early on in life with regular visits to the
dentist started at an early age. Sweets are better consumed after a meal rather than between
meals. Teeth should be cleaned twice daily after breakfast and before bedtime.

Parents require education ante-natally and education should be continued and re-inforced when
parents attend for immunisation and developmental checks.

Obesity in pre-school children can be the parents' fault as young children are totally dependent
on other people for their food. It is easy for sweets, biscuits or crisps to come into the diet in
excess if the child is a faddy eater.
Mealtimes should be a family and social occasion. To encourage this, distractions such as
television should be avoided and meals should be provided on a regular basis with regular
intervals