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Medical Nutrition Therapy Diet: Lactation Brittany Wrasman
1. Purpose a. Mothers who are breastfeeding may be asked to fill out a “Postnatal Nutrition
Risk Screen” as shown below. If the patient answers “yes” to any of the following
nutritional indicators, the registered dietitian must be notified. The patient’s
nutritional status is assessed using the “Breastfeeding/Lactation- Criteria to
Assign Risk” form, as seen below. A total score of 0-5 is representative of a low-
risk patient; 6-10 indicates medium risk; and a score >10 means the patient is at
high risk for nutritional deficiencies. Based on the results, a consult with a
registered dietitian may be initiated to “help the mother optimize her own
nutritional intake and nutritional status in order to ensure optimal breast milk
production (quantity and quality) for her infant’s growth and development (Eat
Right, 2014).”
2. Population a. Overview
i. Breastfeeding provides many health benefits to both the mother and infant.
While breastfeeding, it is important that the mother consumes a healthful
and balanced diet for proper milk production and to meet her nutritional
needs. Breastfeeding burns a significant amount of energy; therefore, a
mother’s energy needs are also increased.
b. Disease Process
i. During pregnancy and lactation, the breasts increase in size due to the
production of milk. The milk is produced in small clusters of cells called
alveoli where it then travels down the milk ducts to the milk sinuses. The
suckling action of the baby creates a suction that causes the milk to flow
into the baby’s mouth from the 15-20 openings present in each nipple.
Nerve stimulation caused from the infant’s suckling triggers the pituitary
gland to release the hormones prolactin and oxytocin. Prolactin causes the
alveoli to take proteins and sugars from the blood supply and turn them
into breast milk. Oxytocin is responsible for the “let-down” reflex, or the
passing of the milk down the ducts (Sutter Health CPMC, 2013). The
mother’s diet correlates directly with her breast milk production and
quality (Eat Right, 2014).
c. Biochemical and Nutrient Needs
i. Women who exclusively breastfeed require an additional 500 kcal/day for
the first 6 months and an additional 400 kcal/day for the second six
months or when using a formula as well (Eat Right, 2014). In addition to
maintaining milk production, meeting these energy needs will promote a
1-2 lb weight loss per month after the first month of feeding.
Breastfeeding mothers are not recommended to consume less than 1,800
3
kcal per day (Eat Right, 2014). Nutrients particularly important while
breastfeeding include protein, calcium, iron, folate, and vitamins A and C
(Better Health Channel, 2011). Mothers who exclusively breastfeed are
recommended to consume a minimum of 65 g of protein per day during
the first six months. This is required for breast milk production in addition
to replacing the mother’s protein stores. Protein needs decrease slightly to
62 g/day after 6 months while weaning (Eat Right, 2014). During
pregnancy, the mother’s iron stores are depleted, which means they need
to be restored post-pregnancy. Some iron rich foods include red meats,
chicken, and fish; legumes; nuts and dried fruit; wholegrain bread and
cereals; and green leafy vegetables. Such foods can be consumed to help
the mother reach her 15 mg/day recommended requirements. Calcium
plays a key role in bone strength and is also a major component of breast
milk. The best food sources for a mother to consume to meet her 1,000
mg/day calcium needs include dairy products (Better Health Channel,
2011). Folate is important in the prevention of major birth defects, but also
plays a role in heart health and preventing cell changes that can lead to
cancer. Folate can be found in leafy vegetables, citrus fruits, beans, and
whole grains (Office of Women's Health, 2012). Folate requirements for a
breastfeeding mother are 500 mcg/day (Eat Right, 2014). Needs for
vitamins A and C increase during lactation to make up for the losses in
breast milk. Foods that commonly contain vitamin A include dark green
and yellow vegetables. Vitamin C is found in citrus fruits, berries,
tomatoes, and potatoes (Better Health Channel, 2011).
3. General Guidelines a. The emphasis during lactation is on educating the mother on how she can meet
her energy needs through a healthy diet while promoting a steady weight loss
back to her pre-pregnancy weight. Educational points would include: what foods
she can consume that will contribute to a healthy diet, the need for sufficient fluid
intake, and the risks of consuming excess amounts of caffeine and alcohol while
breastfeeding.
b. Nutrition Rx
i. Encourage a balanced diet to help the client meet individual requirements
and prevent overconsumption of “empty calories.” Use “MyPlate” as a
tool to educate clients on the appropriate servings needed from each food
group.
c. Adequacy of Nutrition Rx
i. Nutrients needed in increased amounts while breastfeeding include
magnesium, copper, zinc, iodine, selenium, vitamins A, K, and E, and the
B vitamins. A well-balance diet that corresponds to the recommendations
made for breastfeeding women according to MyPlate would be sufficient
to meet these nutrient needs. However, a multivitamin supplement may be
recommended to women who are of lower-economic status or are not
meeting their caloric needs (Eat Right, 2014).
d. Goals (Eat Right, 2014):
i. Optimal nutrition for infant and mother
ii. Normalize body composition gradually so the mother returns to her
ideal/pre-pregnancy weight.
iii. Support the mother to continue breastfeeding for a minimum of 1 year and
thereafter as long as mutually desired.
iv. Decrease the development of nutritional risks in the mother.
v. Promote adequate infant growth and development, including bone
mineralization.
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vi. Discourage use of foods and drinks that should be limited or avoid.
4. Education Material
a. “Tips for Breastfeeding Moms” Facts Sheet
http://www.nal.usda.gov/wicworks/Topics/BreastfeedingFactSheet.pdf
b. Sheets explaining what counts as a serving for each food group necessary for a
balanced diet. https://www.supertracker.usda.gov/foodtracker.aspx
5. Sample Menu a.
24-Hour Recall Suggestions for Improvement Suggested Meal Plan
Breakfast: 2 c. Coffee 4 T. Half and Half Cream 2 T. Splenda 1 Medium Banana
• Drinking a moderate amount (no more than 3 cups/day) of coffee or other caffeinated beverages does not affect your baby (USDA, 2014). However, caffeine can pass into the breast milk, so large amounts of caffeinated beverages should be avoided (Better Health Cannel, 2011).
• Switch to a lower fat or skim milk option to add to your coffee.
• Add two pieces of whole-wheat toast or 1 cup of oatmeal to your breakfast to add some whole grains into your diet and increase your caloric intake for the day.
2 oz. Grains 1 cup Fruits ½ cup Dairy
Lunch: 1 c. FF Greek Yogurt ½ c. Sliced Strawberries ¼ c. LF Granola Ham Sandwich (2 slices white bread, 2 slices deli ham, 1 slice cheddar cheese) 16 oz. Diet Pepsi
• Replace the refine white bread with two slices of whole wheat bread.
• Try switching to a low-sodium deli meat and adding some vegetables to your sandwich such as tomato and lettuce.
• Adding some raw vegetables to your lunch will also help you meet your vegetable needs for the day.
• Try switching the Diet Pepsi out for a glass of water or drink the decaffeinated form.
2 oz. Grains 1 cup Vegetables ½ cup Fruits 1 cup Dairy 2 ½ oz. Protein
Dinner: 2 oz. Baked Chicken (boneless, skinless) 2 c. Spinach (raw) 4 T. Honey Mustard Dressing 1 Large Chocolate Chip Cookie 2 Glasses Wine
• Add a glass of low fat or skim milk to dinner.
• Switch to a reduced fat dressing. • Add some brown rice or whole grain pasta
to your meal to balance your plate off with a grain source.
• Drinking alcohol is not recommended any earlier than 3 months post partum while breastfeeding. Once your child is three months old, it is recommended that you
2 oz. Grains 1 cup Vegetables 1 cup Dairy 3 ½ oz. Protein
6. Websites a. https://www.supertracker.usda.gov/foodtracker.aspx b. http://www.choosemyplate.gov/pregnancy-breastfeeding/breastfeeding-
nurtitional-needs.html
7. References a. Journal articles references
i. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108:776
ii. American Dietetic Association. Position of the American Dietetic Association: Promoting and supporting breastfeeding. J Am Diet Assoc. 2005;105(5):810-818
iii. Dewey, KG. Energy and protein requirements during lactation. Annu Rev Nutr. 1997;17:19-36.
iv. Escott-Stump S. Pregnancy and lactation. In: Nutrition and Diagnosis Related Care. Baltimore: Lippincot, Williams, and Wilkins; 2008: 7-21.
References
Academy of Nutrition and Dietetics (2013). Pocket guide for international dietetics & nutrition
terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, Ill: Academy of Nutrition and Dietetics.
Better Health Channel (2011). Breastfeeding and your diet. Retrieved from
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Breastfeeding_and_your_diet?ope
CDC (2013). Breastfeeding: Frequently Asked Questions (FAQs). Retrieved from
http://www.cdc.gov/breastfeeding/faq/
Dinner: 2 oz. Baked Chicken (boneless, skinless) 2 c. Spinach (raw) 4 T. Honey Mustard Dressing 1 Large Chocolate Chip Cookie 2 Glasses Wine
• Add a glass of low fat or skim milk to dinner.
• Switch to a reduced fat dressing. • Add some brown rice or whole grain pasta
to your meal to balance your plate off with a grain source.
• Drinking alcohol is not recommended any earlier than 3 months post partum while breastfeeding. Once your child is three months old, it is recommended that you wait at least four hours after having a single alcoholic drink before breastfeeding. Or you can breast pump before having a drink and use it to feed your child later (USDA, 2014).
2 oz. Grains 1 cup Vegetables 1 cup Dairy 3 ½ oz. Protein
Snacks: None
• Eating small frequent meals or adding snacks throughout the day will help contribute to a balanced diet and help keep you full and nourished.
• Healthy snack options may include: 1 cup cottage cheese and 1 cup baby carrots; 3 cups popcorn and 16 grapes.
Afternoon Snack: 1 cup Vegetable ½ cup Dairy Evening Snack: 1 oz. Grain ½ cup Fruit
Fluids:
• Staying hydrated while breastfeeding is very important. Each time you nurse the baby, drink a glass of water, with the goal of consuming 8-12 cups a day.
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Eat Right (2014). Breastfeeding/lactation- Nutrition Care Manual. Retrieved from http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=144973&ncm_heading=Nutrition%20Care
Mayo Clinic (2014). Pregnancy weight gain: What's healthy? Retrieved from
http://www.mayoclinic.org/healthy-living/pregnancy-week-by-week/in-depth/pregnancy-weight-gain/art-20044360
Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy and
pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning. Office of Women's Health (2012). Folic acid fact sheet. Retrieved from
http://womenshealth.gov/publications/our-publications/fact-sheet/folic-acid.html Sutter Health CPMC (2013). How milk is produced- Women & Infants Center. Retrieved from
http://www.cpmc.org/services/pregnancy/information/breastfeeding-milkproduction.html USDA (2014). Nutritional Needs while Breastfeeding. Retrieved from
http://www.choosemyplate.gov/pregnancy-breastfeeding/breastfeeding-nurtitional-needs.html
USDA (2014). SuperTracker. Retrieved from
https://www.supertracker.usda.gov/foodtracker.aspx USDA (2013). Tips for Breastfeeding Moms. Retrieved from
http://www.nal.usda.gov/wicworks/Topics/BreastfeedingFactSheet.pdf