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Letters to LLLI:
Dietary Choices and DHA Supplementation

From: LEAVEN, Vol. 34 No. 5, October-NOvember 1998, p. 102-103

We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time

Dear LLLI,

Much is being said about breastfeeding in the news these days. As a Leader I try to pay attention when I hear or read about new information. Occasionally a mother will come to me with questions about something she read or heard in the media.

Recently a mother who follows a vegan diet (no meat, fish, dairy products or eggs) asked me about an article on DHA (docosahexaenoic acid) supplementation.

She worried that because she does not consume eggs or fish her breast milk might be low in DHA. She referred to an article in Pediatrics (January 1998) that states that "DHA is an important building block, essential to infant brain and eye development." It also says that American mothers typically have low breast milk DHA levels.

THE WOMANLY ART OF BREASTFEEDING, page 339, states that "human milk contains significant amounts of DHA and AA, which are long-chain polyunsaturated fatty acids derived from linoleic and linolenic acid. These fats are important to the process of myelination, the development of the sheath around nerve fibers that enables them to send messages. This process is critical during baby's first year and the presence of these particular fats in baby's diet may be important." However, nothing is said about levels of DHA in a vegan mother's milk.

As a Leader I tell mothers that LLL believes in good nutrition from a well-balanced diet of foods as close to their natural state as possible. However, since my family is vegan, I wondered about DHA supplementation myself. There is so much information in the media today and many mothers, at least in my area, have adopted a vegan diet. I'd like to be able to support these mothers with LLL information that responds to statements like those in popular press articles on DHA. A mother who has eliminated foods from her diet due to allergy might have similar questions.

Please help me find answers for mothers with such concerns.

Sincerely,

Jessica Rigney
Petersburg, Illinois, USA

Dear Jessica,

Thank you for your interest in this matter. When mothers are anxious about issues that may present unique problems, it is essential for Leaders to seek sufficient information to fully address their concerns. Usually a Leader can put the mother at ease once this information is gathered from LLL resources. By offering information, making suggestions and discussing options, a Leader can help a mother sort out her problems so she can make up her own mind. It is particularly important to be sensitive to the concerns of mothers who come from varied backgrounds.

Articles in the popular press often contain information that calls attention to an isolated aspect of a research study. These articles may cause alarm where none was initially intended, especially when they attempt to address a complex, controversial issue, for example, dietary supplementation. In order to sort fact from supposition or opinion, it becomes important to consult the original medical research to put popular media reports into perspective.

Breastfeeding is recommended for all infants throughout the world under ordinary circumstances, even if the maternal diet is not perfect. Particular problems may exist for preterm infants born with low fat reserves due in part to an insufficient intrauterine supply of fatty acids like DHA. However, international organizations have been impressed by the strong evidence that mothers are able to produce milk of sufficient quantity and quality to support growth and promote the health of infants in a wide variety of situations.

At the present time there are very few specific recommendations for improving the nutritional status of lactating women. Some suggestions have been made to improve nutrient intakes of women with eating patterns that excessively restrict food intake or a diet providing a poor source of one or more nutrients considered by many nutrition authorities to be important for good health. For example, THE WOMANLY ART OF BREASTFEEDING (1997 edition, page 226) states that, "A mother who is on a vegan or macrobiotic diet that includes no animal protein may need to take a vitamin B12 supplement in order to avoid a vitamin B12 deficiency in her baby." However, it does not mention concerns about low levels of certain fatty acids in the breast milk of vegan mothers because there does not appear to be universal agreement that such concerns are valid.

The dietary long-chain fatty acid, docosahexaenoic acid (DHA), has been the focus of several research studies that have found it positively associated with the neurological and visual development of preterm and, to some extent, full-term breastfed infants.

Levels of DHA in breast milk vary with maternal intake. Mothers with diets high in fish consumption have elevated breast milk levels of DHA, while lactating mothers with omnivorous diets have intermediate levels. Vegan mothers, who consume no animal products and therefore no DHA, do have low levels of DHA in their breast milk, probably due to maternal synthesis of DHA from another dietary fat, alpha-linolenic acid (ALA). The amount of DHA in breast milk appears to depend on a complex interaction of maternal fat stores, synthesis from ALA and consumption of dietary DHA. What significance does this hold for nursing mothers?

One recent preliminary study found that maternal DHA supplements increased DHA levels in breast milk, yet the authors confirmed that recommendations regarding supplementation of the diet of lactating women must await further studies. This study found no evidence that maternal diets low in particular fatty acids (e.g., vegan diets) are deficient or pose problems for nursing infants.

While some researchers have reported that pregnant and lactating mothers are deficient in long-chain polyunsaturated fatty acids (LCPUFAs) and therefore have increased dietary requirements, there have been no reports of clinical conditions related to lowered LCPUFA levels in these women. Many other investigators suggest that before supplements are recommended, further research needs to determine the biochemical and physiological consequences of varying levels of breast milk DHA on infant development. For example, populations of mothers who consume large amounts of fish should be studied to see if there are any problems in their breastfed infants related to the higher levels of DHA in their breast milk.

Breastfeeding is recommended world-wide for healthy, full-term infants when at all possible. There is no clear consensus that DHA supplements are needed or advised for lactating women; instead, human milk is recommended as an appropriate source of DHA. Neither the United Nations Food and Agriculture Organization nor the World Health Organization has recommended DHA supplements for nursing mothers. The American Academy of Pediatrics and the Food and Drug Administration (US) do not recommend DHA supplementation either.

Nutrition and Breastfeeding (No. 159) also reminds mothers that "before eliminating any important food from your diet, be sure to talk to a doctor or nutritionist about alternative foods or a vitamin mineral supplement." The choice to take any dietary supplement is ultimately up to the mother and her health care provider.

THE WOMANLY ART OF BREASTFEEDING emphasizes that although dietary supplements do not substitute for nutritious foods, lactating women may need to take certain supplements to avoid deficiencies in themselves and their infants. La Leche League's basic approach to good nutrition for all nursing mothers is to continue to recommend eating a well-balanced and varied diet of foods in as close to their natural state as possible, supplementing only when essential nutrients are not, for some reason, present in the mother's diet. A Leader can recommend the mother seek the advice of a nutritionist or health care provider if she has questions about supplements.

Sincerely,
Marty O'Donnell, PhD
US Western Division Professional Liaison Resource Advisor
Park Ridge, Illinois, USA

Ed. Note: See also Wolk, M. The vegetarian breastfeeding mother. LEAVEN Jun/Jul 1997; 69.

Special thanks to Laure Marchand Lucas, International Division Administrator of Professional Liaison Resources, and Dr. E.A.M. de Deckere of the Unilever Nutrition Center in the Netherlands for their contributions to this article. Laure, a family physician and IBCLC, co-leads a Group in Paris, France.

References

Joint Food and Agriculture Organization (FAO)/ Health Organization (WHO) Expert Consultation. Fats and oils in human nutrition. FAO Food and Nutrition Paper 57 1994.

Horwood, L., Fergusson, D. Breastfeeding and later cognitive and academic outcomes. Pediatrics Jan 1998; 101:e9.

Makrides, M., Neumann, M., Gibson, R. Effect of maternal docosahexaenoic acid (DHA) supplementation on breast milk composition. European journal of Clinical Nutrition 1996; 50:352-57.

Mohrbacher, N. Nutrition and Breastfeeding. LLLI, Jan 1994. Publication No. 159a.

Mohrbacher, N., Stock J. BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: LLLI, 1997.

National Academy of Sciences Nutrition During Lactation Washington, D.C.: National Academy Press, 1991.

THE WOMANLY ART OF BREASTFEEDING 6th ed. Schaumburg, Illinois; LLLI. 1997.

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