The Vegetarian Breastfeeding Mothers

The Vegetarian
Breastfeeding Mother
Collaborate by Karen Ho, dated 16 August 2013

INDEX
2. Vitamin B12 and Vegetarian Diets
• Vitamin B12 Deficiency
• Digestion and absorption of Vitamin B12
• Vegetarians and Vitamin B12 status
• Vegetarians infants and Vitamin B12 status
• Vitamin B12 in the vegetarian diets
• Vegetarian meal plan and food sources
1. Know Your Option. Know Your Right
• Traditional After-Birth Care Theory and Nutrition
• Case Study
Valerie Lynn
Post Pregnancy Wellness Coach
Collaborate and prepare by Karen Ho, Interaction Designer, IT
Medical Journal of Australia
3. A balanced vegetarian diest supports healthy breasfeeding
• Calories Needs and Weigh Loss
• High calorie, high nutrient foods
• Fluids Needs
• Meal plannning guidelines for breastfeeding vegetarians
• Important nutrients
Vegetarian Diets During Lactation

INDEX
5. The Vegetarian Breastfeeding Mothers
• Vegan and Types of Vegan
• Breastfeeding Mothers on vegan diets
4. Healthy eating for vegan pregnant and breastfeeding mothers
Queensland Dietitians
Last reviewed: June 2013
Leaders, USA
6. A balanced vegetarian diest supports healthy breasfeeding
• Infants Formulas
• Formula Milk and Soya Milk
• The Best Diets for Breastfeeding
• Weigh Loss and Milk Loss
• Protein Requirement
Vegan Baby and Children
The Vegan Society
7. Breastfeeding Mothers and Fenugreek
Breastfeeding and Herbs

INDEX
9. Prenatal and Postnatal Care, Feeding and Dietary
8. Nutrient Adequacy of Exclusive Breastfeeding for the Term Infant
During the First Six Month of Life
World Health Organization
Geneva WHO 2002
Pre-Post Natal Care
10. How much milk do my baby need?
Estimating and Calculation of Expressed Milk

Know your option, know your right
Traditional After-Birth Care Theory and Nutrition
By Choicesinchildbirth
Valerie Lynn is American’s first Post-pregnancy Well-
ness Coach and founder of the Post-pregnancy Well-
ness Company.
She is introducing an entirely new paradigm regard-
ing after birth care in the United States based on
Eastern influences. Her book, The Mommy Plan, Re-
storing Your Post-pregnancy Body Naturally Using Women’s Tradi-
tional Wisdom, is gaining global recognition in the child birth industry
as she has explained core tenants of traditional after birth guidelines
surrounding a mother’s diet, activities and personal care during the
first 6-8 weeks after child birth. Valerie is the International Country Co-
ordinator of Malaysia, for Postpartum Support International (PSI); and
is on the Board of Advisors for the After Birth Project, a documentary-
in-the-making on the lack of after birth support in the United States
and the social effects. Valerie is the first foreigner, in Malaysia, to be
university strained in traditional after birth care and is a practicing Tra-
ditional Postpartum Practitioner. She offers training in traditional after
birth care, herbal body treatments, massage and abdominal wrapping,
and is the Sole US distributor of a unique traditional Postnatal Care
Set.
Resources: By Valerie Lynn, Author, The Mommy Plan
This entry was posted on March 7, 2013 at 3:06 pm and is filed under Postpartum Health
Website URL: http://choicesinchildbirth.wordpress.com/category/postpartum-health/

Case Study: By Valerie Lynn, Author, The Mommy Plan
In May 2007, I returned to the U.S. after living in Asia for ten years. That
same month, I gave birth to my son, Jordan. I quickly realized that in the
United States specific, structured care for mothers after delivery didn’t
exist – and still doesn’t today. I’ve asked myself why this is the case
many times over the years. Care during the first six weeks post-natally
is deemed as a crucial healing period to at least three billion people
around the globe. Why is this period not deemed as equally important in
my own country, where we have at least 4 million births per year? I at-
tribute this to the medicalization of birth and the diminished role of the
midwife, beginning in the early 1900s. Our heritage of after-birth care
has been lost. There is no longer an understanding of the transition of a
woman’s body back to a non-pregnant state and the intense healing pro-
cess that goes on in those first few weeks.
The Humoral Theory of Medicine
All after-birth traditions, practices, and guidelines are based on one of
the oldest scientific theories in the world, the Humoral Theory of Medi-
cine. According to this ancient theory, there are four conditions in the
human body: hot, cold, moist, and dry, and they must remain in balance.
The Humoral Theory of Pregnancy states that a woman’s body is out of
balance and in a hot state while pregnant, as her body primarily func-
tions as an incubator to support a growing and developing baby. The hot
state is due to additional sources of heat, such as: raised level of hor-
mones, baby’s body heat, the placenta and amniotic fluid, as well as a
50% increase in the volume of blood. All of these factors combine to
raise a mother’s body temperature throughout pregnancy by 1-1.5°F. In
fact, the first scientific pregnancy test was an elevated temperature for
two weeks outside of the menstruation period.
When a baby is born, a mother’s body temperature drops the same
amount, 1-1.5°F below the normal body temperature. The decrease is
due to the loss of heat sources, namely the baby’s body heat, the pla-
centa, amniotic fluid, and blood, along with exhaustion from labor. At this
time the mother’s body shifts into a cold state and the Humoral Theory
of Medicine can be applied to the post-pregnancy period, when the body
is again out of balance.

Sustaining & Raising Body Temperature
Traditional post-pregnancy recovery guidelines emphasize the impor-
tance of raising a mother’s internal body temperature at a consistent
pace over the six weeks after delivery. Therefore, all guidelines sur-
rounding a mother’s diet and beverage intake, personal care, and activ-
ity during this time are based on the notion that, due to the mother’s
body being in a cold state, the remaining heat must be protected and
maintained, ensuring no body heat escapes. In addition, a post-baby
body has specific nutritional and energetic temperament needs than
when it was in a pregnant state, which can be met by consuming nutrient
dense healing foods.
Heaty foods are Healing Foods
A traditional after birth diet, whether from Asia, Latin America or else-
where, is one where food is used as medicine to help accelerate the
body’s natural healing capabilities. Since a mama’s body is in a cold
state after delivery, only heaty foods should be consumed. The word
‘heaty’ refers to the capacity of a particular food, herb or spice to gener-
ate a “hot sensation” and warming within the body. This is not to be con-
fused with food being overly spicy, a taste sensation that provides a
sharp spicy taste and causes sweating. That sort of heat is not good for
a mama’s recovering body.
Foods deemed as having a cold temperament should not be consumed
during the healing period after delivery, as this may delay the natural in-
crease in body temperature and shock the body’s digestive system. In
turn, this could interrupt the healing process, lower body temperature
further, and prolong the recovery process.
Most vegetables are considered to have a cold temperament and theo-
retically shouldn’t be consumed at this time. However, the coldness may
be counteracted by the way the vegetables are prepared. For example,
adding fresh ginger root while cooking makes vegetables “warm,” thus
acceptable to eat and good for recuperation.
A nutritious, wholesome, and natural diet should always be encouraged.
However, even good foods can be trouble for the digestive system
during the immediate post-pregnancy period due to the unique state of
a mama’s body after delivery.

Some of the traditional foods to avoid are nutritious and healthy such as
broccoli, tomatoes and cauliflower. Please take note that it is only
during the post-birth recovery period, when the body is in a weakened
state, that specific foods should be avoided; by no means are they per-
manent recommendations.
Post-pregnancy Dietary Plan
After childbirth you should continue to eat well. One hour after the pla-
centa is birthed the body begins its transition back to a non-pregnant
state. Over the first six weeks postpartum a mama’s body goes through
an intense internal workout as a significant amount of healing takes
place. Pregnancy is approximately 259 – 280 days or 37-40 weeks, and
in just 42 days or six weeks, (medically speaking) the physical shrink-
age of the perinatal organs is back to normal and most of the loss of re-
tained water, fat, and gas takes place. This healing time equates to 15%
of the total amount of time spent in a pregnant state. With this in mind,
don’t you think a post-pregnancy dietary plan is just as important as a
dietary plan during pregnancy? Three billion people around the globe
do.
By avoiding foods that interfere with the healing process you allow your
body to have a stronger and more balanced recovery in a shorter period
of time.
Don’t Underestimate Traditional Post-Pregnancy Care
The childbirth industry is in transition as more mothers are searching for
ways to help speed up their recovery after childbirth. The United States
is one of only four countries in the world that does not require employ-
ers to provide paid maternity care. Women therefore need to return to
work as soon as they are able. Western countries are no longer under-
estimating the effectiveness of traditional post-pregnancy care, but
trying to understand them. As women across the world are embracing
more natural products and services into their lifestyles, western mamas
are searching for natural ways to recover from childbirth. Post-pregnan-
cy care that facilitates healing at a faster rate is becoming increasingly
valued in modern cultures where women must resume their normal
lives within weeks after delivery.

8/15/13 Vitamin B12 and vegetarian diets | Medical Journal of Australia
https://www.mja.com.au/open/2012/1/2/vitamin-b12-and-vegetarian-diets 1/11
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Clinical focus
Vitamin B12 and vegetarian diets
Carol L Zeuschner, Bevan D Hokin, Kate A Marsh, Angela V Saunders, Michelle A Reid and Melinda R Ramsay
MJA Open 2012; 1 Suppl 2: 27-32. doi:10.5694/mjao11.11509
Abstract
Vitamin B12 is found almost exclusively in animal-based foods and is therefore a nutrient of potential concern for
those following a vegetarian or vegan diet. Vegans, and anyone who significantly limits intake of animal-based
foods, require vitamin B12-fortified foods or supplements.
Vitamin B12 deficiency has several stages and may be present even if a person does not have anaemia. Anyone
following a vegan or vegetarian diet should have their vitamin B12 status regularly assessed to identify a potential
problem.
A useful process for assessing vitamin B12 status in clinical practice is the combination of taking a diet history,
testing serum vitamin B12 level and testing homocysteine, holotranscobalamin II or methylmalonic acid serum
levels.
Pregnant and lactating vegan or vegetarian women should ensure an adequate intake of vitamin B12 to provide
for their developing baby.
In people who can absorb vitamin B12, small amounts (in line with the recommended dietary intake) and
frequent (daily) doses appear to be more effective than infrequent large doses, including intramuscular injections.
Fortification of a wider range of foods products with vitamin B12, particularly foods commonly consumed by
vegetarians, is likely to be beneficial, and the feasibility of this should be explored by relevant food authorities.
Vitamin B12 (cobalamin) is an essential vitamin, required for DNA synthesis (and ultimately cell division) and for
maintaining nerve myelin integrity. It is found almost exclusively in animal-based products including red meats, poultry,
seafood, milk, cheese and eggs. As vitamin B12 is produced by bacteria in the large intestines of animals, plant-based
foods are generally not a source of vitamin B12. It is therefore a nutrient of concern for vegetarians and particularly for
vegans who choose an entirely plant-based diet. A cross-sectional analysis study involving 689 men found that more than
half of vegans and 7% of vegetarians were deficient in vitamin B12.
Vitamin B12 deficiency
Vitamin B12 deficiency is a serious health problem that can result in megaloblastic anaemia, inhibition of cell division, and
neurological disorders. Folate deficiency can also cause megaloblastic anaemia and, although a high folate intake may
correct anaemia from a vitamin B12 deficiency, subtle neurological symptoms driven by the vitamin B12 deficiency may
arise. Loss of intrinsic factor, gastric acid or other protein-digesting enzymes contributes to 95% of known cases of
vitamin B12 deficiency. Other factors that may contribute to vitamin B12 deficiency are listed in Box 1. However, in
vegetarian and vegan populations, dietary insufficiency is the major cause. Furthermore, high levels of folate can mask
vitamin B12 deficiency — a concern for vegetarians and vegans whose folate intake is generally high while vitamin B12
intake is low. The addition of vitamin B12 to any foods fortified with folate has been advocated to prevent masking of
haematological and neurological manifestations of vitamin B12 deficiency. Subtle neurological damage (even in the
absence of anaemia) may be more likely in vegans because of their increased folate levels preventing early detection of
vitamin B12 deficiency.
Vitamin B12 deficiency can also lead to demyelinisation of peripheral nerves, the spinal cord, cranial nerves and the brain,
resulting in nerve damage and neuropsychiatric abnormalities. Neurological symptoms of vitamin B12 deficiency include
numbness and tingling of the hands and feet, decreased sensation, difficulties walking, loss of bowel and bladder control,
memory loss, dementia, depression, general weakness and psychosis. Unless detected and treated early, these
symptoms can be irreversible.
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Digestion and absorption of vitamin B12
The digestion of vitamin B12 begins in the stomach, where gastric secretions and proteases split vitamin B12 from
peptides. Vitamin B12 is then free to bind to R-factor found in saliva. Pancreatic secretions partially degrade the R-factor,
and vitamin B12 is then bound to intrinsic factor. Intrinsic factor binds to the ileal brush border and facilitates the
absorption of vitamin B12. Box 2 illustrates the process of vitamin B12 digestion and absorption. Vitamin B12 absorption
may decrease if intrinsic factor production decreases. There are many well documented factors causing protein-bound
vitamin B12 malabsorption, including gastric resection, atrophic gastritis, and the use of medications that suppress acid
secretion (see Box 1).
Up to 89% of vitamin B12 consumed in the diet is absorbed, although as little as 9% is absorbed from some foods
(including eggs). This relatively high rate of absorption, combined with low daily requirements and the body’s
extremely efficient enterohepatic circulation of vitamin B12, contributes to the long period, often years, for a deficiency to
become evident. Studies have been inconsistent in linking the duration of following an unsupplemented vegan diet with
low serum levels of vitamin B12. Intestinal absorption is estimated to be saturated at about 1.5–2.0 µg per meal, and
bioavailability significantly decreases as intake increases.
Ageing causes a decreased level of proteases, as well as a reduced level of acid in the stomach. As a result, vitamin B12 is
less effectively removed from the food proteins to which it is attached, and food-bound vitamin B12 absorption is
diminished. The Framingham Offspring Study found that the vitamin B12 from supplements and fortified foods may be
more efficiently absorbed than that from meat, fish and poultry.
While low vitamin B12 status in vegetarians and vegans is predominantly due to inadequate intake, some cases of
pernicious anaemia are attributable to inadequate production of intrinsic factor. Under the law of mass action, about 1%
of vitamin B12 from large oral doses can be absorbed across the intestinal wall, even in the absence of adequate intrinsic
factor.
Assessing vitamin B12 status
Taking a simple diet history can be a useful indicator of vitamin B12 intake and adequacy. However, laboratory analyses
provide a much more accurate assessment. Measurement of serum vitamin B12 levels is a common and low-cost method
of assessing vitamin B12 status. The earlier method of measuring vitamin B12 using biological assays was unreliable, as
both the active and inactive analogues of vitamin B12 were detected, so levels were often overestimated. Modern radio
isotope and immunoassay methods reliably measure biologically available analogues of vitamin B12. The early measured
ranges of acceptable levels of serum vitamin B12 were determined using individuals who were apparently healthy but had
potentially marginal levels of vitamin B12. This has resulted in reference intervals probably being set too low to provide a
reliable clinical decision. To improve the ability to predict marginal vitamin B12 status, a higher reference interval (> 360
pmol/L) has been proposed. Objective measures of neurological damage have been found in patients with vitamin B12
levels below 258 pmol/L. However, the usual reference interval for vitamin B12 deficiency is < 220 pmol/L. Achieving
national and international agreement on the definition of serum vitamin B12 deficiency would provide some clarity for
comparison of studies and reduce variability in defining those at risk of deficiency. Internationally, the cut-off for vitamin
B12 varies markedly between < 130 pmol/L and < 258 pmol/L.
Serum vitamin B12 levels alone do not provide a measure of a person’s reserves of the vitamin. It is recommended that a
metabolic marker of vitamin B12 reserves, such as serum homocysteine, also be determined. Elevated homocysteine
levels can be a useful indicator for vitamin B12 deficiency, because serum homocysteine levels increase as vitamin B12
stores fall. While serum homocysteine levels greater than 9 µmol/L suggest the beginning of depleted vitamin B12
reserves, standard laboratory reference intervals suggest levels greater than 15 µmol/L as a marker for depleted
vitamin B12 reserves. Although homocysteine levels may also increase with folate or vitamin B6 deficiency, these
deficiencies are likely to be rare in vegetarians and vegans.
Other markers for vitamin B12 deficiency include serum holotranscobalamin II (TC2) and urinary or serum methylmalonic
acid (MMA). TC2 is the protein that transports vitamin B12 in blood, and its levels fall in vitamin B12 deficiency. Testing for
this carrier protein can identify low vitamin B12 status before total serum vitamin B12 levels drop. Vitamin B12 is the only
coenzyme required in the conversion of methylmalonyl-CoA to succinyl-CoA, so methylmalonyl-CoA levels increase with
vitamin B12 deficiency. As it is toxic, methylmalonyl-CoA is converted to MMA, which accumulates in the blood and is
excreted in the urine, enabling either urinary or serum MMA to be a useful measure of vitamin B12 reserves. Because TC2
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is one of the earliest markers of vitamin B12 deficiency, it may be one of the better means of assessing vitamin B12
status.
Requirements
Box 3 shows the vitamin B12 nutrient reference values for Australia and New Zealand. As no recommended dietary
intakes (RDIs) are available for infants under 12 months of age, an adequate intake is recommended instead. Vegans at
all stages of the life cycle need to ensure an adequate and reliable source of vitamin B12 from fortified foods, or they will
require supplementation equivalent to the RDI.
Vegetarians and vitamin B12 status
While reported cases of frank vitamin B12 deficiency in vegetarians or vegans are rare, several studies have found lower
vitamin B12 levels in vegans and vegetarians compared with the general population. The European Prospective
Investigation into Cancer and Nutrition (EPIC)-Oxford cohort study found that 121 of 232 vegans (52%), 16 of 231
vegetarians (7%) and one of 226 omnivores (0.4%) were classed as vitamin B12-deficient. There was no significant
association between age or duration of subjects’ adherence to a vegetarian or vegan diet and the serum levels of vitamin
B12. Intuitively, it is assumed that prevalence of deficiency increases with a longer duration of vegetarian diet. Although it
can take years for deficiency to occur, it is likely that all vegans and anyone who does not regularly consume animal-
based foods, and whose diets are unsupplemented or unfortified, will eventually develop vitamin B12 deficiency.
Vegetarians and vegans should have their vitamin B12 status regularly assessed to enable early intervention if levels fall
too low.
Vegetarian infants and vitamin B12 status
The risk of a breastfed infant becoming deficient in vitamin B12 depends on three factors: the vitamin B12 status of the
mother during pregnancy; the vitamin B12 stores of the infant at birth; and the vitamin B12 status of the breastfeeding
mother. The fetus obtains its initial store of vitamin B12 via the placenta, with newly absorbed vitamin B12 (rather than
maternal stores) being readily transported across the placenta. Under normal conditions, full-term infants will have
enough stored vitamin B12 at birth to last for about 3 months when the maternal diet does not contain vitamin B12. An
infant born to a vegetarian or vegan mother is at high risk of deficiency if the mother’s vitamin B12 intake is inadequate
and her stores are low. Vegetarian women who have repeated pregnancies place infants at greater risk, because their
vitamin B12 stores are likely to have been depleted by earlier pregnancies. Vegetarian or vegan women must have a
balanced diet, including adequate intake of vitamin B12, to provide for their babies during both pregnancy and lactation.
Recent studies suggest that maternal stores of vitamin B12 are also reflected in breastmilk. When maternal serum vitamin
B12 levels are low, vitamin B12 levels in breastmilk will also be low, and the infant will not receive an adequate vitamin B12
intake.
There have been reports of deficiency in the breastfed infants of vegan (or “strict vegetarian”) mothers who did not
supplement their diets with vitamin B12, because of the smaller stores of vitamin B12 gained by the infant during
pregnancy and the low vitamin B12 content of breastmilk (reflective of the mothers’ serum levels). Infants have
presented with a range of symptoms, often initially signalled by developmental delay. Lack of vitamin B12 in the
maternal diet during pregnancy has been shown to cause severe retardation of myelination in the nervous system of the
infant. Visible signs of vitamin B12 deficiency in infants may include involuntary motor movements, dystrophy,
weakness, muscular atrophy, loss of tendon reflexes, psychomotor regression, cerebral atrophy, hypotonia and
haematological abnormalities. While supplementation with vitamin B12 results in rapid improvements in laboratory
measures of vitamin B12 status, there is continuing research about the long-term effects of deficiency in infants.
Vitamin B12 in the vegetarian diet
Lacto-ovo-vegetarians will have a reliable source of vitamin B12 in their diet, provided they consume adequate amounts of
dairy products and eggs, although their intake is likely to be lower than in meat eaters. However, those who follow a
vegan diet will not have a reliable intake unless they consume foods fortified with vitamin B12 or take a supplement.
It was once thought that some plant foods, such as spirulina, and fermented soy products, including tempeh and miso,
were dietary sources of vitamin B12, but this has been proven incorrect. Recent research has found traces of vitamin
B12 in white button mushrooms and Korean purple laver (nori), but the quantity in a typical serving means that they
are not a significant dietary source of this vitamin. An average serving of mushrooms contains about 5% of the RDI,
making the quantity required to supply adequate amounts of vitamin B12 to vegetarians impractical. Further, use of
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Korean laver is unlikely to be widespread in the Australian diet. With the unique exception of these two plant foods,
any vitamin B12 detected in other plant foods is likely to be the inactive analogue, which is of no use to the body and can
actually interfere with the absorption of the active form.
Box 4 shows a sample vegetarian meal plan for a 19–50-year-old woman, which includes food sources typical in a
Western-style diet and meets the RDI of vitamin B12 and requirements for other key nutrients (except vitamin D and long-
chain omega-3 fatty acids). Excluding or limiting dairy foods or fortified soy milk from the vegetarian diet would
necessitate the need for vitamin B12 supplements.
Fortified foods
In contrast to the United States, where foods are extensively fortified with vitamin B12, Food Standards Australia New
Zealand permits only a limited number of foods to be fortified with vitamin B12. This includes selected soy milks, yeast
spread, and vegetarian meat analogues such as soy-based burgers and sausages. Examples of the vitamin B12 content of
foods suitable for vegetarians are shown in Box 5.
Vitamin B12 added to foods is highly bioavailable, especially in people with vitamin B12 deficiency caused by inadequate
dietary intake. An unpublished Australian study (Hokin BD. Vitamin B12 deficiency issues in selected at-risk populations
[PhD thesis]. Newcastle: University of Newcastle, 2003) compared the effectiveness of fortified soy milk (two servings of
250 mL/day), soy-based meat analogues (one serving/day), vitamin B12 supplements (one low-dose tablet/day or one
high-dose tablet/week) and vitamin B12 intramuscular injections (one injection/month) in raising serum vitamin B12 levels
in subjects with deficiency. The study found that fortified foods were superior to the traditional methods of
supplementation (intramuscular injections and tablets). Further research would be beneficial to confirm these findings.
With inadequate dietary intake being a risk for vegetarians and vegans, further fortification of foods commonly consumed
by this population with vitamin B12 would be beneficial and should be considered by the relevant authorities.
Supplements
In a vegan diet, using a supplement or consuming fortified foods is the only way to obtain vitamin B12. As the body can
only absorb a limited amount of vitamin B12 at any one time, it is better to take small doses more often, instead of large
doses less often. One study found that small doses of vitamin B12 in the range of 0.1–0.5 µg resulted in absorption
ranging between 52% and 97%; doses of 1 µg and 5 µg resulted in mean absorption of 56% and 28%, respectively, while
higher doses had even lower absorption, with 10 µg and 50 µg doses resulting in 16% and 3%, respectively, being
absorbed. While sublingual supplements are often promoted as being more efficiently absorbed, there is no evidence to
show that this form of supplement is superior to regular oral vitamin B12. Vitamin B12 supplements are not made from
animal-based products and are suitable for inclusion in a vegan diet.
Conclusion
Vitamin B12 deficiency is a potential concern for anyone with insufficient dietary intake of vitamin B12, including those
adhering to a vegan or vegetarian diet or significantly restricting animal-based foods. Studies have found that vegetarians,
particularly vegans, have lower serum vitamin B12 levels, and it is likely that anyone avoiding animal-based foods will
eventually become deficient if their diet is not supplemented. All vegans, and lacto-ovo-vegetarians who don’t consume
adequate amounts of dairy products or eggs to provide sufficient vitamin B12, should therefore supplement their diet with
vitamin B12 from fortified foods or supplements. It is particularly important that pregnant or breastfeeding vegan and
vegetarian women consume a reliable source of vitamin B12 to reduce the risk of their baby developing a vitamin B12
deficiency.
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Box 1 – Causes of vitamin B12 deficiency, with contributing factors (#)
Inadequate dietary intake
Restrictive diet or dieting; vegetarian or vegan diets without supplementation or use of fortified foods
Inadequate absorption or impaired utilisation
Loss of intrinsic factor, loss of gastric acid and/or other protein-digesting enzymes (contributes to 95% of known
cases)
Use of medications that suppress acid secretion, including somatostatin, cholecystokinin, atrial natriuretic peptide,
4
5

and nitric oxide
Pancreatic disease
Gastric resection, sleeve or banding surgery
Ileal disease or ileal resection (secondary to Crohn’s disease)
Use of metformin (oral hypoglycaemic agent)
Use of angiotensin-converting enzyme inhibitor
Use of levodopa and catechol-O-methyltransferase inhibitors
Autoimmunity to intrinsic factor
Gastric infection with Helicobacter pylori
Ileocystoplasty
Atrophic gastritis
Increased requirements
During pregnancy and lactation
Increased excretion
Alcoholism
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Box 2 – Diagram illustrating vitamin B12 digestion and absorption (#)15 ,16
Box 3 – Recommended dietary intake (RDI)* and estimated average requirement (EAR) of
vitamin B12 per day (#)
†
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Sex and age group
RDI EAR
Men = 19 years 2.4 µg 2.0 µg
Women = 19 years 2.4 µg 2.0 µg
Pregnant women 2.6 µg 2.2 µg
Lactating women 2.8 µg 2.4 µg

Children
0–6 months 0.4 µg
7–12 months 0.5 µg
1–3 years 0.9 µg 0.7 µg
4–8 years 1.2 µg 1.0 µg
9–13 years 1.8 µg 1.5 µg
14–18 years 2.4 µg 2.0 µg
* The RDI is the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all healthy individuals (97%–98%) of a
particular sex and life stage. The EAR is a daily nutrient level estimated to meet the requirements of half the healthy individuals of a particular sex and life
stage. These values are adequate intakes, which are the average daily nutrient intake levels based on observed or experimentally determined
approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate.
‡
‡
†
‡
Box 4 – A sample vegetarian meal plan designed to meet requirements for vitamin B12 and
other key nutrients for a 19–50-year-old woman, showing vitamin B12 content of the foods* (#)
Meal Vitamin B12 content
Breakfast
Bowl of cereal with fruit, and poached egg on toast
2 wholegrain wheat biscuits 0.0 µg
4 strawberries 0.0 µg
10 g chia seeds 0.0 µg
1/2 cup low-fat fortified soy milk (or dairy milk) 0.5 µg (0.8 µg)
1 slice multigrain toast 0.0 µg
1 poached egg 0.9 µg
Snack
Nuts and dried fruit
30 g cashews 0.0 µg
6 dried apricot halves 0.0 µg
Lunch
Chickpea falafel wrap
1 wholemeal pita flatbread 0.0 µg
1 chickpea falafel 0.0 µg
30 g hummus 0.0 µg
1/2 cup tabouli 0.0 µg
Salad 0.0 µg
†

Provenance: Commissioned by supplement editors; externally peer reviewed.
Snack
Banana and wheatgerm smoothie
3/4 cup low-fat fortified soy milk (or dairy milk) 0.8 µg (1.1 µg)
2 teaspoons wheatgerm 0.0 µg
1 banana 0.0 µg
Dinner
Stir-fry greens with tofu and rice
100 g tofu 0.0 µg
2 spears asparagus, 1/3 cup bok choy and 25 g snow peas 0.0 µg
1 cup cooked brown rice 0.0 µg
Snack
Fortified malted chocolate beverage
1 cup low-fat fortified soy milk (or dairy milk) 1.0 µg (1.5 µg)
10 g malted chocolate powder 0.0 µg
Total vitamin B12 3.2 µg (4.3 µg)
* Source: FoodWorks 2009 (incorporating Food Standards Australia New Zealand’s AUSNUT [Australian Food and Nutrient Database] 1999), Xyris Software,
Brisbane, Qld. Figures are for soy milk (dairy milk).
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†
†
†
Box 5 – Vitamin B12 content of lacto-ovo-vegetarian food sources* (#)
Vegetarian sources Vitamin B12 per 100 g
Sausage, vegetarian style, fortified 2.0 µg
Cheese, cheddar, reduced fat (16%) 1.8 µg
Egg (chicken), whole, poached 1.7 µg
Milk, cow, fluid, regular or reduced fat 0.6 µg
Soy beverage, unflavoured, regular fat, fortified 0.9 µg
Soy beverage, unflavoured, reduced fat (1.5%), fortified 0.9 µg
Soy beverage, unflavoured, low fat, (0.5%), fortified 0.3 µg
Yoghurt dessert, regular fat, flavoured 0.2 µg
* From Food Standards Australia New Zealand. NUTTAB 2010 online searchable database.43

Correspondence: carol.zeuschner@sah.org.au (mailto:carol.zeuschner@sah.org.au)
Acknowledgements: We acknowledge the assistance of dietitians Sue Radd and Rebecca Prior in the early development stages of this article.
Competing Interests:
Kate Marsh previously consulted for Nuts for Life (Horticulture Australia), who are providing a contribution towards the cost of publishing this
supplement. Angela Saunders, Michelle Reid and Melinda Ramsay are employed by Sanitarium Health and Wellbeing, sponsor of this
supplement.
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Carol L Zeuschner, BSc, MSc, APD, Manager of Nutrition and Dietetics
Bevan D Hokin, BSc, MAppSc, PhD, Director of Pathology
Kate A Marsh, AdvAPD, MNutrDiet, PhD, Director and Senior Dietitian
Angela V Saunders, BS(Dietetics), MA(Ldshp&Mgmt–HS), APD, Senior Dietitian, Science and Advocacy
Michelle A Reid, BND, APD, AN, Senior Dietitian, Nutrition Marketing
Melinda R Ramsay, BMedSci, MNutrDiet, APD, Project Coordinator
1 Sydney Adventist Hospital, Sydney, NSW.
2 Northside Nutrition and Dietetics, Sydney, NSW.
3 Corporate Nutrition, Sanitarium Health and Wellbeing, Berkeley Vale, NSW.
4 Sanitarium Health and Wellbeing Services, Sanitarium Health and Wellbeing, Sydney, NSW.
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Vegetarian Diets During Lactation
RD Resources for Consumers:
A balanced vegetarian diet supports
healthy breastfeeding.
Lower levels of environmental toxins are found
in milk from women who follow a vegetarian
diet. Breastfed children of well-nourished
vegetarian mothers grow and develop normally.
Benefits of Breastfeeding
Breast milk is best. It provides all the nutrients
a growing infant needs in the most digestible
form. Breastfeeding is free, convenient and
supports mother-child bonding. The most
benefits are gained when children are breastfed
for at least the first 6 months after birth. Children
build stronger immune systems, suffer from less
allergies, and have reduced risk of obesity later
in life. Mothers reduce their risk of some cancers,
and type 2 diabetes.
Calorie Needs and Weight Loss
The body uses extra calories when producing
breast milk. Increased calorie needs are based
on the amount of milk produced. On average,
women use 330 more calories each day for the
first 6 months of breastfeeding. During the
second 6 months, they use an additional 400
calories. While this will aid in healthy weight loss
after pregnancy, extra calorie intake will also be
needed. To meet higher calorie needs, consume
plenty of whole-grains, fruits, vegetables,
legumes, nuts, and seeds.
Visit http://www.mypyramid.gov/mypyramidmoms/
breastfeeding_weight_loss.html for more information.
Tandem Nursing
When a woman nurses two children of different ages it is
called“tandem nursing.”Producing milk for two children
requires more calories and nutrients than needed to feed
one. High calorie and high nutrient foods in snacks and meals
provide good sources of additional calorie intake. Remaining
hydrated, by drinking extra water, is also highly recommended.
High calorie, High nutrient foods
• Avocado
• Nuts & nut butters
• Seeds & seed butters
• Dried fruits
• Full-fat soy products
• Bean spreads
• Fruit juices
300-Calorie Snack Ideas
• Whole-grain toast with 1½ tbsp. almond butter topped
with sliced banana and strawberries
• ½ cup hummus with 1 cup of raw carrots and bell peppers
• Fruit smoothie with 1 cup frozen mango, ½ cup frozen
pineapple, 1 cup soymilk
• ¼ cup guacamole with 1/3 cup baked tortilla chips
• ¼ cup of trail mix
Fluid Needs
Fluid needs increase while breastfeeding, therefore staying
hydrated is key. Drink water throughout the day and while
nursing. Low-fat or non-fat milk, 100% fruit juices, and soups
are also good sources of fluid.
tip

Important Nutrients
Protein (.59 g/lb.)
Example: A woman who weighs 150 lbs. would
need approximately 89 g of protein per day
(150 lbs x .59 g/lb = 88.5 g)
• Dried beans
• Tofu & Tempeh
• Nuts & nut butters
• Eggs
• Soymilk
• Whole-grains
• Dairy products
Omega-3 Fatty Acid-DHA
• Eggs from chickens fed a DHA-rich diet
• Foods fortified with microalgae-derived
DHA
Vegetarian & Vegan-friendly DHA
supplements may be used.
Vitamin B12 (2.6 mcg/day)
• Fortified cereals
• Fortified soymilk
• Vitamin B12-fortified nutritional yeast
• Milk and yogurt
• Eggs
Calcium (1,000 mg/day)
• Fortified soymilk or rice milk
• Dairy products
• Calcium-set tofu
• Some dark green leafy vegetables
(e.g. broccoli, kale, collard greens, bok choy)
• Soybeans
• Almonds
• Figs
• Fortified orange juice
Vitamin D (200 IU/day)
• Cow’s milk
• Fortified cereals
• Vitamin D-fortified soymilk
• Skin exposure to sunlight
Breastfed infants should be given a 400
IU vitamin D supplement daily.
tip
tip
RD Resources are a project of the Vegetarian Nutrition Dietetic Practice Group. More topics available at
www.VegetarianNutrition.net. Professional resources also available for members at www.VNDPG.org. © 2010 by VN DPG.
Written by: Christine Creighton, MS, RD
Expires April 2015.
RD Resources for Consumers: Vegetarian Diets During Lactation
Choose high calcium foods from each of the food groups (e.g. calcium-fortified breakfast cereals, bok choy, broccoli, collards, Chinese cabbage,
kale, mustard greens, okra, calcium-fortified orange juice, dairy products, calcium-fortified soy milk, tempeh, calcium-set tofu, almonds).
tip
Resources
MyPyramid for Pregnancy & Breastfeeding,
http://www.mypyramid.gov/mypyramidmoms/
index.html
Raising Vegetarian Children by Joanne
Stepaniak and Vesanto Melina
Simply Vegan, 4th ed. by Debra Wasserman
and Reed Mangels
The Vegetarian Mother’s Cookbook by
Cathe Olson
Meal Planning Guidelines for Breastfeeding Vegetarians
Food Group
Grains
Vegetables
Fruits
Legumes, nuts,
seeds, milks
Fats
# of Svgs.
6
4
2
7
2
Serving Size
1 slice bread; ½ cup cooked cereal or
pasta; ¾ - 1 cup ready-to-eat cereal
½ cup cooked vegetables; 1 cup raw
vegetables; ¾ cup vegetable juice
½ cup canned fruit; 1 medium fruit;
¾ cup fruit juice
½ cup cooked beans, tofu, tempeh,
textured vegetable protein (TVP); 3 ounces
meat analog; 2 tbsp. nuts, seeds, nut or
seed butter; 1 cup fortified soy or rice milk;
1 cup cow’s milk; 1 cup yogurt
1 tsp. oil or margarine
Comments
Choose whole or enriched grains
Choose these calcium-rich foods often: dark green
leafy vegetables (kale, collards, and mustard
greens), broccoli, bok choy, Chinese cabbage, okra
Choose these calcium-rich foods often: calcium-
fortified juice, figs
Choose these calcium-rich foods often: calcium-
fortified soymilk, cow’s milk, yogurt, calcium-set
tofu, almond butter, tahini, tempeh, almonds,
cheese, soybeans
The MyPyramid for Pregnancy and Breastfeeding Web site (www.mypyramid.gov/tips_resources/vegetarian_diets.html) provides
meal plans that can be adapt for breastfeeding women who follow lacto-ovo and lacto vegetarian diets. MyPyramid for Pregnancy
and Breastfeeding offers limited information for women following vegan diets. The following meal plan can be used for pregnant
vegans. These guidelines are the suggested minimum number of servings for breastfeeding women. Some women may need
additional servings and/or added fats to maintain desirable body weight.

This is a consensus document by Queensland Dietitians. Last reviewed: June 2013
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp Review: June 2015
Healthy eating for vegan pregnant and breastfeeding mothers
Healthy eating is important at all stages of
life, especially during pregnancy. Your
choices of what to eat and drink at this
time can affect your health and the health
of your baby for many years to come. A
well planned vegan diet is able to meet
nutrition requirements for pregnancy and
breastfeeding.
There is only a small increase in the
amount of food you need to eat while you
are pregnant. However, you do need
more of certain nutrients, so it is very
important that you make good choices for
a nutritious diet. This is important so you
and your baby get all you need for
healthy growth and a healthy pregnancy.
Healthy eating is important when you are
breastfeeding. Your body has a greater
need for most nutrients. Some of the
extra energy required for breastfeeding
comes from body fat stored during
pregnancy. To meet your extra nutrient
needs, it is important to eat a variety of
nutritious foods.
Your daily food group requirements
during pregnancy and breastfeeding are
outlined in the table on the next page.
Use the numbers in the middle column to
guide how many serves to eat from each
food group per day. One serve is equal to
each of the foods in the column on the
right. For example, one serve of fruit is
equal to 2 small plums. One serve of
grain (cereal) foods is equal to ½ cup of
cooked pasta.

Food Group Number of Serves 1 serve
Vegetables and
legumes/ beans
Pregnant
5
Breast
Feeding
7½
½ cup cooked green or orange
vegetables (e.g. broccoli, carrot,
pumpkin or spinach)
½ cup cooked, dried or canned beans,
chickpeas or lentils (no added salt)
1 cup raw leafy green vegetables
½ medium potato, or other starchy
vegetable (sweet potato, taro, or
cassava)
½ cup sweet corn
75 g other vegetables e.g. 1 small-
medium tomato
Fruit Pregnant
2
Breast
Feeding
2
1 piece medium sized fruit (e.g. apple,
banana, orange, pear)
2 pieces smaller fruit (e.g. apricot, kiwi
fruit, plums)
1 cup diced, cooked or canned fruit
½ cup 100% juice
30 g dried fruit (e.g. 1½ tbsp sultanas, 4
dried apricot halves)
Grain (cereal) foods
Pregnant
8½
Breast
Feeding
9
1 slice of bread
½ medium bread roll or flat bread
½ cup cooked rice, pasta, noodles,
polenta, quinoa, barley, porridge,
buckwheat, semolina, cornmeal
⅔ cup breakfast cereal flakes
¼ cup muesli
3 crisp breads
1 crumpet or 1 small English muffin or
scone
Nuts, seeds and
legumes
Pregnant
3½
Breast
Feeding
2½
1 cup (170 g) cooked dried beans,
lentils, chickpeas, split peas, canned
beans
170 g tofu
1/3 cup (30 g) unsalted nuts, seeds or
paste, no added salt
Dairy alternatives Pregnant
2½
Breast
Feeding
2½
1 cup (250 ml) calcium fortified soy milk
200 g (3/4 cup) calcium fortified soy
yoghurt
2 (40 g) slices of soy cheese
Additional serves for
taller or more active
women
0–2½
3–4 sweet biscuits
30 g potato crisps
2 scoops soy ice-cream
1 Tbsp (20 g) dairy-free butter,
margarine, oil

Protein
Pregnant or breastfeeding women should
aim to include protein sources at each
meal such as nuts, seeds, soy products
and dried beans and peas.
Folate or Folic acid during pregnancy
Folate (or folic acid) is needed for the
growth and development of your baby. It
is especially important in the month
before you fall pregnant and the first
trimester (three months) of pregnancy. A
good intake of folate reduces the risks of
your baby being born with some
abnormalities such as spina bifida (a
disorder where the baby’s spinal cord
does not form properly). Dietary sources
high in folate include green vegetables
such as broccoli, spinach and salad
greens, some fruits and fortified cereals.
All women planning a pregnancy and in
the early stages of pregnancy should eat
a variety of folate-containing foods (e.g.
green leafy vegetables such as spinach,
broccoli, bok choy, and foods fortified with
folic acid— fruit juice, bread, breakfast
cereal). You should also take a folic acid
supplement of 400 micrograms per day at
least one month before and three months
after you become pregnant.
Iron during pregnancy
Iron is needed to form the red blood
cells for you and your baby. It helps
carry oxygen in your blood and is
needed for your baby to grow. During
pregnancy you need a lot more iron
than when you are not pregnant so for
women who follow a vegan diet an iron
supplement is highly recommended.
Good sources of additional dietary iron
are legumes, (e.g. beans, peas, lentils)
dark green vegetables, dried fruits,
nuts, fortified soy milks, breakfast
cereals and wholemeal breads.
Vitamin C will help its absorption, so
combine it with citrus fruit, berries,
juice or tomato. Talk to your dietitian or
midwife to make sure you are getting
enough iron from your diet.
What you eat or drink can stop your body
using iron from your diet. You should limit
your intake of these. They include:
• drinking tea or coffee with meals
• eating more than 2 tablespoons of
unprocessed bran.
You can help your body get iron from the
food you eat or drink by:
• including vitamin C with meals
(e.g. citrus foods, tomato,
capsicum)
• using antacids sparingly.

Iodine
Adequate iodine in pregnancy is essential
for your baby’s growth and brain
development. Iodine is needed in higher
amounts during pregnancy. It is now
recommended that all pregnant women
should take a supplement containing 150
micrograms of iodine. You still need to
consume good food sources of iodine in
addition to this supplement. These food
sources include:
- iodised salt (look for green label)
- bread with added iodine
- fortified margarine.
Fluid
When you are breastfeeding you need
more to drink to replace the fluid used in
breast milk (~700 ml/day). It is a good
idea to have a drink, such as a glass of
water or fat reduced milk (within your
nutrition needs) every time your baby
feeds. You will also need to drink more
fluid at other times during the day too.
Multivitamin supplements
A folate supplement is important during
the first trimester of pregnancy. You may
also need to take an iron supplement if
your iron levels are low. However, a
multivitamin during pregnancy is not
necessary unless you do not have a
balanced diet – compare what you are
eating with the table on the first page of
this sheet.
If you choose to take a vitamin or mineral
supplement during pregnancy, choose
one that is specifically designed for
pregnancy. Always check with your
doctor before taking any supplements as
an excessive intake of these can be
harmful and reduce the absorption of
other nutrients.
Calcium
Calcium fortified soy products are
important to meet calcium requirements
whilst pregnant. Also include tofu,
almonds, sesame seeds and tahini.
Vitamin B12
Significant amounts of B12 are usually
found in animal products, so your intake
will be limited. A good amount can be
consumed by having at least two serves
of soy milk fortified with B12 daily. Food
fermented by micro-organisms (soy
sauce, miso, tempeh), manure-grown
mushrooms, spirulina and yeast may
contain small amounts of vitamin B12, but
this is not sufficient to meet your
requirements for vitamin B12. Discuss
your vitamin B12 levels and requirements
with your doctor or midwife.

Zinc
Good sources for vegans include beans
and lentils, yeast, nuts, seeds and
wholegrain cereals. Pumpkin seeds
provide one of the most concentrated
vegan food sources of zinc.
Weight Gain
The amount of weight to gain during
pregnancy will depend on what your
weight was before you became pregnant.
Your midwife or dietitian will be able to
calculate your body mass index (BMI) (a
measure of your weight for height) to help
you work this out.
If your pre-pregnancy
BMI was…
You should gain…
Less than 18.5 kg/m²
18.5 to 24.9 kg/m²
25 to 29.9 kg/m²
Above 30 kg/m²
12½ to 18kg
11½ to 16kg
7 to 11½ kg
5 to 9kg
As well as having an overall weight gain
goal for your pregnancy, there is a
trimester by trimester guideline to follow,
as well.
How much should I gain in my first
trimester?
All women can expect to gain one or
two kilograms in the first three months
of pregnancy.
How much should I gain in my
second and third trimesters?
This depends on your pre-pregnancy
BMI. Refer to the table below to see
your goal.
If your pre-pregnancy
BMI was…
You should gain…
Less than 18.5 kg/m² ½ kg/week
18.5 to 24.9 kg/m² 400g/week
Above 25kg/m² Less than 300g/ week
It is important to keep your weight gain in
this range for both your health and the
health of your baby. Not gaining enough
weight means your baby may miss out on
some important nutrients. This can cause
problems later in life. Insufficient weight
gain is also linked with preterm birth.
Gaining too much weight during
pregnancy can also cause problems such
as high blood pressure, gestational
diabetes, complications in delivery, and
longer hospital stays for you or your baby.
These problems can be harmful to both
you and your baby.

Food safety during pregnancy
Hormonal changes during pregnancy may
make your immune system weaker. This
can make it harder to fight infections.
Foods are sometimes a source of
infections so protecting yourself from food
poisoning is important.
Listeria
Listeria is a bacteria found in some foods,
which can cause an infection called
listeriosis. If passed on to your unborn
baby it can cause premature birth,
miscarriage or damage. The risk is the
same through your whole pregnancy.
Always keep your food ‘safe’ by:
• Choose freshly cooked and freshly
prepared food.
• Thawing food in the fridge or
defrosting food in the microwave.
• Cooling left over food in the fridge
rather than the bench.
• Wash your hands, chopping
boards and knives after handling
raw foods.
• Make sure hot foods are hot
(above 60 degrees Celsius) and
cold foods are cold (below 5
degrees Celsius), both at home
and when eating out.
• Make sure all food is fresh, used
within the used-by date.
• Eat left overs within 24 hours and
reheat foods to steaming hot.
• Heat leftovers to above 74 degrees
for over 2 minutes.
• Never re-freeze food once it has
been thawed.
• Ready-to-eat salads (from salad
bars, buffets, supermarkets etc.)
are foods that may contain Listeria
and should be avoided.
Some other bacteria and parasites can be
harmful to your unborn baby.
In addition to the precautions above:
• Wear gloves when gardening and
wash hands afterwards.
• Avoid contact with cats and use
gloves when handling cat litter
(cats can be a source of
Toxoplasmosis– a serious infection
that can cause defects or death in
your baby).

Special Considerations during
Pregnancy
Caffeine
During pregnancy caffeine takes longer to
break down in your body. Generally 2–3
cups of coffee or up to 4 cups of tea a
day are okay, but decaffeinated drinks
are a better alternative. Try to limit your
intake of caffeine containing drinks and
foods.
Alcohol
Alcohol crosses the placenta and can
lead to physical, growth and mental
problems in babies. There is no known
safe level of alcohol consumption during
pregnancy. The safest option is not to
drink during your pregnancy.
Nausea and vomiting
Many women suffer from sickness,
usually in early pregnancy. Morning
sickness is usually caused by the
hormonal changes of pregnancy, and can
affect you at any time of the day. By the
end of the 4th
month of pregnancy,
symptoms usually disappear or become
much milder. Some tips to help morning
sickness:
• Eat small amounts every two hours
— an empty stomach can cause
nausea.
• Avoid smells and foods that make
your sickness worse.
• Eat more nutritious carbohydrate
foods: try dry toasts or crackers,
breakfast cereals and fruit.
• Eat less fatty and sugary foods.
Heartburn
Heartburn, or reflux, is a burning feeling
in the middle of the chest that can also
affect the back of the throat. It is caused
when acid moves from the stomach, back
up the oesophagus. This happens
because hormonal changes during
pregnancy relax stomach muscles, and
also because as the baby grows, more
pressure is put on your stomach.
Some tips to reduce heartburn:
• eat small regular meals more often
• avoid fatty, fried or spicy foods
• avoid tea, coffee, cola drinks,
chocolate drinks and alcohol
• sit up straight while eating
• do not bend after meals or wear
tight clothes
• sleep propped up on a couple of
pillows.

Constipation
Constipation is common during
pregnancy. Hormone changes may relax
the muscles in your bowel, which together
with pressure from the growing baby can
slow down your bowel movements. It is
important to have enough fibre, fluid and
exercise to avoid constipation.
Good sources of dietary fibre include;
vegetables, fruit, wholegrain and high
fibre breakfast cereals, wholegrain bread,
nuts, seeds and legumes. Water is the
best drink.
Now that you are up to date on healthy eating for yourself you need to start thinking
about nutrition for you baby when he or she arrives.
Mothers & Babies are designed for
Breastfeeding
Breastfeeding is the natural, normal way
to feed your baby.
Breastmilk is a complex food. It changes
to meet the particular needs of each child
from the very premature baby to the older
toddler.
Food for Health
Breastfeeding has an amazingly positive
effect on the health of both mothers and
babies.
For this reason, the World Health
Organisation (WHO) and the Australian
Department of Health recommend that all
babies are breastfed exclusively (ie. no
other food or drinks) for around the first 6
months and then continue to receive
breastmilk (along with complementary
food and drink) into the child’s 2nd year
and beyond.
Research shows that the longer the
breastfeeding relationship continues, the
greater the positive health effects.
Breastmilk provides:
Protection for baby from infections
such as ear, stomach, chest and
urinary tract; diabetes, obesity, heart
disease, some cancers, some
allergies and asthma.
Protection for mother from breast and
ovarian cancers, osteoporosis and
other illnesses.
Healthier communities & environment.

Preparing to Succeed
Research shows that nearly all of women
are able to meet the breastmilk needs of
their babies. Ask the midwife to put your
baby skin to skin on your chest as soon
as possible after birth. Take the midwife
up on her offer to help your baby lead
attachment to your breast. Talk to your
family, friends and workplace about your
decision to breastfeed so they are ready
to support you once your baby has
arrived.
Avoiding certain foods during
breastfeeding
Mothers may be told to avoid certain
foods when breastfeeding. However,
there is no evidence to support the claims
that either colic or allergic reactions in
infants are caused by the mother’s diet.
Allergic reactions are rare in breast fed
babies. If this does occur, the mother’s
diet should only be modified in
consultation with her doctor and dietitian
Trying to lose weight while
breastfeeding
Breast feeding helps you shape up.
The greatest amount of weight loss
generally occurs in the first 3 months after
birth and then continues at a slow and
steady rate until 6 months after birth.
Breastfeeding your baby should help you
return to your pre-pregnancy weight, as
some of the fat stores you laid down
during pregnancy are used as fuel to
make breast milk. Continue breastfeeding
for at least 12 months, into the second
year of life and for as long as you and
your baby & are happy to continue.
When you are trying to lose your
pregnancy weight, it is important you do
not follow a very restrictive diet plan. You
need to make nutritious breast milk and
stay healthy yourself.
Try these helpful hints:
• Follow the meal plan in this
handout or similar.
• Do not skip meals.
• Limit foods high in fat and sugar
such as lollies, chocolate, soft
drinks, cakes, sweet biscuits, chips
and fatty take-away food.
• Use healthy cooking methods such
as steaming, boiling, microwaving,
grilling and stir frying.
• Do some gentle exercise such as
taking your baby for a walk. If
available attend physiotherapy
postnatal classes.
• Plan your healthy meals and
snacks ahead of time.

Are you losing weight too quickly?
If you are losing too much weight when
you are breastfeeding it is important you
do not stop breastfeeding.
Instead, find ways to eat more nutritious
foods. Try these suggestions:
• Don’t skip meals.
• Have three main meals and three
between-meal snacks.
• Keep easy to prepare nutritious
snacks on hand (e.g. crisp-breads
and cheese, fresh fruit, soy
yoghurt, nuts, seeds, dried fruit,
canned beans, fruit smoothies,
breakfast cereals and soy milk).
• Prepare a packed lunch or variety
of snacks to have in a container
beside you when breastfeeding.
• Prepare and freeze meals in
advance when possible (or ask
your friends/family to help).
• Plan your healthy meals & snacks
ahead of time.
For further breastfeeding information go to www.health.qld.gov.au/breastfeeding/
Things I can do to improve my diet for a healthy pregnancy and/or while breastfeeding:
1.
2.
3.
4.
For further information contact your Dietitian or Nutritionist:_____________________
References:
1. Eat for Health Australian Dietary Guidelines. 2013. Commonwealth of Australia.
2. Foods Standards Australia and New Zealand, Listeria and food fact sheet, 2005.
3. Food Standards Australia and New Zealand, Mercury in Fish fact sheet, 2004.
4. Institute of Medicine (2009). Weight Gain During Pregnancy: Re-examining the Guidelines, National Academies Press.
5. National Health and Medical Research Council (2010), Public Statement, Iodine Supplementation for pregnant and breastfeeding
women.
6. National Health and Medical Research Council (2006). Nutrient Reference Values for Australia and New Zealand Executive
Summary. Dept. Health and Ageing. Canberra, Commonwealth of Australia.
7. Queensland Health. Optimal infant nutrition: evidence-based guidelines 2003-2008.Queensland Health Brisbane 2003.
8. World Health Organisation. Global Strategy for Infant and Young Child Feeding. World Health Organisation, 2003.
9. World Health Organisation. Infant Feeding: The Physiological Basis. 1996. James Akre (ed), WHO, Geneva.
10. Zimmermann M, Delange F. Iodine supplementation of pregnant women in Europe: a review and recommendations. Eur JClin Nutr
2004;58:979-984.

The Vegetarian Breastfeeding Mother
Mel Wolk
St. Peters, Missouri, USA
From: LEAVEN, Vol. 33 No. 3, June-July 1997, p. 69
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.
Ed. Note: From time to time, Leaders receive questions about diet from vegetarian mothers. The BREASTFEEDING ANSWER BOOK
is a helpful resource.
Vegetarian diets include several variations:
Vegan - no flesh foods (red meat, poultry, fish), milk products or eggs. Ovo-lacto vegetarian - no
flesh foods but milk products and eggs are allowed. Ovo vegetarian - no flesh foods or milk prod-
ucts, but eggs are allowed. Lacto vegetarian - no flesh foods or eggs, but milk products are al-
lowed.
Vegetarian diets that contain no animal protein may require vitamin B12 supplementation to avoid
a deficiency in mother or baby. In babies, symptoms may include loss of appetite, regression in
motor development, lethargy, muscle atrophy, vomiting or blood abnormalities. Mothers of babies
with symptoms may or may not exhibit symptoms themselves.
Mothers on vegan diets who do not consume animal products do have alternatives. They can ask
their health care provider about using a vitamin B12 supplement or adding fermented soybean
foods and yeast (both contain some vitamin B12) to their diets. Another option would be to ask
their health care provider about the need to supplement the baby with vitamin B12.
Even though one study showed vegetarian mothers tend to consume less calcium than other
mothers, levels of calcium in human milk were not affected. This is believed to be caused by the
fact that vegetarians consume less protein and therefore need less calcium.
Vegetarian mothers who do not consume milk or other dairy products will want to take special
care to eat foods rich in calcium. One cup (227 grams) of cooked bok choy, a type of cabbage,
will provide 86% of the calcium in one cup (240 ml.) Of milk. One half cup (113 grams) of ground
sesame seeds contains twice as much calcium as one cup (240 ml.) of milk. Other sources of
calcium include blackstrap molasses, tofu, collard greens, spinach, broccoli, turnip greens, kale,
almonds and Brazil nuts.
While vegetarian mothers in the same study had low vitamin D levels, supplements are not usu-
ally recommended because most mothers and babies receive adequate vitamin D through expo-
sure to the sun. Research suggests that women with dark skin, or those who wear traditional, en-
veloping clothing that allows little exposure of skin to sunlight may need to consider a vitamin D
supplement for themselves or their babies.
The milk of vegetarian mothers is lower in environmental contaminants than the milk of non-
vegetarian mothers. Environmental contaminants are stored mainly in fat. Vegetarian diets tend
to be lower in fat than those containing animal products, so there is less transfer into human milk.
Leaders can assure vegetarian mothers that their diet should not present a problem when breast-
feeding their babies.

References
Dagnelie P. et al. Nutrients and contaminants in human milk from mothers on macrobiotic and ominivorous
diets. European Journal of Clinical Nutrition 1992; 46:355-66.
Fuhrman, J. Osteoperosis: how to get it and how to avoid it. Health Science Jan/Feb 1992; 8-11.
Kuhn, T. et al. Maternal vegan diet causing a serious infantile neurological disorder due to vitamin B12 defi-
ciency. European Journal of Clinical Nutrition 1991; 150:205-08.
Lawrence, R. Breastfeeding: A Guide for the Medical Profession, 4th ed. St. Louis: Mosby; 1994, pp. 104-15,
290-91, 300-02, 657.
Specker, B. Nutritional concerns of lactating women consuming vegetarian diets. American Journal of Clinical
Nutrition 1994; 54(Suppl): 1182S-86S.

Infant Formulas
Unfortunately there is currently no infant formula available which is suitable for vegans.
There are soya formulas on the market, such as SMA’s Wysoy and Cow and Gate’s
Infasoy, but these are not 100% vegan as they are fortified with vitamin D3, which is
made from lanolin (a grease produced by sheep’s skin and extracted from their wool).
The vegan-suitable formula which was previously available, Heinz Nurture Soya
(formerly Farley’s Soya), is no longer manufactured as Heinz no longer produce any
infant formulas.
Formula Milk & Soya Milk
Some concern has been expressed regarding the relationship between the glucose
content of soya formula and tooth decay in children. The energy content is based on
glucose syrup rather than lactose (milk sugar) and it has been thought to have a
greater potential to contribute to dental caries than cow's milk formulas. No studies
have shown that soya infant formula is any more harmful to teeth than dairy infant for-
mula. Feeds from a bottle, feeding at bedtime, prolonged sucking, may be the most
important factors in predicting caries development (Moynham et al 1996). If normal
weaning practices are adopted, infant formulas should not cause harm to teeth. When
bottle feeding, do not allow prolonged or frequent contact of milk feeds with your
baby's teeth since this increases the risk of tooth decay. As soon as the first tooth
erupts (usually appears any time between 6 and 12 months although they may come
through sooner or later than this) brush twice daily. Make sure your baby's teeth are
cleaned after the last feed at night and try to wean your baby off the bottle by the age
of one.
Glucose syrup has several properties that make its use in soya formulas appropriate. It
is easily absorbed and utilised by infants even when the gut mucosa is damaged. The
use of glucose syrup as the carbohydrate in a soya formula ensures a similar osmolal-
ity to breast milk. Glucose syrup is easily mixed with water, which is essential for home
preparation, and the naturally bitter taste of soya protein is effectively masked by glu-
cose syrup without causing undue sweetness.
Formula should be fed from a feeding bottle. However, between the ages of six and 12
months a beaker or cup should be increasingly used. The use of a bottle should not be
prolonged and teeth should be cleaned after feeds. Regarding tooth decay, evidence
indicates that the quantity of sugar eaten is less important than the time taken to con-
sume them and the interval before further sugar is eaten. If sugary foods or drinks are
consumed, it is better to ensure they are finished relatively quickly rather than eaten
over several hours as the mouth pH can be restored within 30 minutes.
It is important that ordinary soya milk should not substituted for soya infant formula as
it does not contain the proper ratio of protein, fat, carbohydrate, nor the vitamins and
minerals required to be used as a sole food. Soya milk should also not be substituted
to babies under 6 months of age because it has levels of protein which are too high
and excessive protein intake is thought to be medically undesirable at this stage.

Breastfeeding and Fenugreek
Betty H. Greenman: Posted on Wednesday, July 10, 2013 3:06 PM
Many moms are interested in increasing their milk supply. The number one
choice is Fenugreek. Fenugreek is an herb that many moms say that it increases
their milk supply in only a few days. Fenugreek comes in capsule, powder seed
or tea form. Some moms even get creative and bake cookis with Fenugreek in
them.
You should discuss using Fenugreek with your doctor before you get started
taking this. If you have a history of diabetes, hypoglycemia, asthma, abnormal
menstrual cycles, peanut or chickpea allergies, migraines, blood pressure
problems, or heart disease, Fenugreek is not for you.
When the mother takes large amounts of Fenugreek, sometimes she smells
like maple syrup. Also, the baby can smell like maple syrup. Sometimes this can
be misleading because there is a serious metabolic disorder that babies can be
misdiagnosed as having. Also, Fenugreek is an herb related to the peanut family.
Therefore, people who have allergies to peanuts, need to stay away. Some
babies may have upset stomachs or even diarrhea when mom takes Fenugreek.
Some women experience upset stomachs as well. Although herbs are natural,
they are not always safe to use. Therefore, breastfeeding moms should be cau-
tious when taking Fenugreek.
The Food and Drug Administration (FDA) is mandated to control medications
and infant formulas in the United States. However, they do not control herbs.
Therefore, there are no requirements to list ingredients on the label. Furthermore,
some herbs interfere with other medications so speak to your doctor before taking
Fenugreek.
In conclusion, always discuss any supplemental herbs you are taking while
breastfeeding with your doctor. Many women today take Fenugreek in a pill form.
Most vitamins and many supermarkets carry this product.If you or your baby are
experiencing any side effects, stop taking Fenugreek immediately.
Resources: http://bit.ly/1b0Gdrc

DEPARTMENT OF NUTRITION FOR HEALTH AND DEVELOPMENT
DEPARTMENT OF CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT
WORLD HEALTH ORGANIZATION
NUTRIENT ADEQUACY
OF EXCLUSIVE
BREASTFEEDING
FOR THE TERM INFANT
DURING THE FIRST
SIX MONTHS OF LIFE

The World Health Organization was established in 1948 as a specialized agency of the United Nations serving as the directing
and coordinating authority for international health matters and public health. One of WHO’s constitutional functions is to
provide objective and reliable information and advice in the field of human health, a responsibility that it fulfils in part
through its extensive programme of publications.
The Organization seeks through its publications to support national health strategies and address the most pressing public
health concerns of populations around the world. To respond to the needs of Member States at all levels of development,
WHO publishes practical manuals, handbooks and training material for specific categories of health workers; internationally
applicable guidelines and standards; reviews and analyses of health policies, programmes and research; and state-of-the-art
consensus reports that offer technical advice and recommendations for decision-makers. These books are closely tied to the
Organization’s priority activities, encompassing disease prevention and control, the development of equitable health systems
based on primary health care, and health promotion for individuals and communities. Progress towards better health for all
also demands the global dissemination and exchange of information that draws on the knowledge and experience of all
WHO’s Member countries and the collaboration of world leaders in public health and the biomedical sciences.
To ensure the widest possible availability of authoritative information and guidance on health matters, WHO secures the
broad international distribution of its publications and encourages their translation and adaptation. By helping to promote
and protect health and prevent and control disease throughout the world, WHO’s books contribute to achieving the
Organization’s principal objective — the attainment by all people of the highest possible level of health.

GENEVA
WORLD HEALTH ORGANIZATION
2002
NUTRIENT ADEQUACY OF
EXCLUSIVE BREASTFEEDING FOR
THE TERM INFANT DURING THE
FIRST SIX MONTHS OF LIFE
NANCY F. BUTTE, PHD
USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics,
Baylor College of Medicine, Houston, TX, USA
MARDIA G. LOPEZ-ALARCON, MD, PHD
Nutrition Investigation Unit, Pediatric Hospital, CMN, Mexico City, Mexico
CUTBERTO GARZA, MD, PHD
Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA

WHO Library Cataloguing-in-Publication Data
Butte, Nancy F.
Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life / Nancy F. Butte, Mardia
G. Lopez-Alarcon, Cutberto Garza.
1.Breastfeeding 2.Milk, Human – chemistry 3.Nutritive value 4.Nutritional requirements 5.Infant I.Lopez-Alarcon,
Mardia G. II.Garza, Cutberto III.Expert Consultation on the Optimal Duration of Exclusive Breastfeeding (2001 : Geneva,
Switzerland) IV.Title.
ISBN 92 4 156211 0 (NLM Classification: WS 125)
© World Health Organization 2002
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The named authors alone are responsible for the views expressed in this publication.
Designed by minimum graphics
Printed in France

Contents
iii
R E F E R E N C E S
Abbreviations & acronyms v
Foreword vii
Executive summary 1
1. Conceptual framework 3
1.1 Introduction 3
1.2 Using ad libitum intakes to assess adequate nutrient levels 3
1.3 Factorial approaches 4
1.4 Balance methods 5
1.5 Other issues 6
1.5.1 Morbidity patterns 6
1.5.2 Non-continuous growth 6
1.5.3 Estimating the proportion of a group at risk for specific nutrient deficiencies 6
1.5.4 Summary 7
2. Human-milk intake during exclusive breastfeeding in the first year of life 8
2.1 Human-milk intakes 8
2.2 Nutrient intakes of exclusively breastfed infants 8
2.3 Duration of exclusive breastfeeding 8
2.4 Summary 14
3. Energy and specific nutrients 15
3.1 Energy 15
3.1.1 Energy content of human milk 15
3.1.2 Estimates of energy requirements 15
3.1.3 Summary 15
3.2 Proteins 16
3.2.1 Dietary proteins 16
3.2.2 Protein composition of human milk 16
3.2.3 Total nitrogen content of human milk 17
3.2.4 Approaches used to estimate protein requirements 17
3.2.5 Protein intake and growth 20
3.2.6 Plasma amino acids 21
3.2.7 Immune function 21
3.2.8 Infant behaviour 22
3.2.9 Summary 22

3.3 Vitamin A 22
3.3.1 Introduction 22
3.3.2 Vitamin A in human milk 22
3.3.3 Estimates of vitamin A requirements 23
3.3.4 Plasma retinol 23
3.3.5 Functional end-points 24
3.3.6 Summary 26
3.4 Vitamin D 26
3.4.2 Factors influencing the vitamin D content of human milk 26
3.4.3 Estimates of vitamin D requirements 27
3.4.4 Vitamin D status and rickets 29
3.4.5 Vitamin D and growth in young infants 29
3.4.6 Vitamin D and growth in older infants 30
3.4.7 Summary 30
3.5 Vitamin B6 30
3.5.2 Vitamin B6 content in human milk 30
3.5.3 Approaches used to estimate vitamin B6 requirements 31
3.5.4 Estimates of requirements 31
3.5.5 Vitamin B6 status of breastfed infants and lactating women 31
3.5.6 Growth of breastfed infants in relation to vitamin B6 status 32
3.5.7 Summary 32
3.6 Calcium 32
3.6.1 Human milk composition 32
3.6.2 Estimates of calcium requirements 32
3.6.3 Summary 33
3.7 Iron 34
3.7.2 Estimates of iron requirements 34
3.7.3 Summary 35
3.8 Zinc 35
3.8.2 Estimates of zinc requirements 35
3.8.3 Summary 37
References 38
N U T R I E N T A D E Q U A C Y O F E X C L U S I V E B R E A S T F E E D I N G F O R T H E T E R M I N F A N T D U R I N G T H E F I R S T S I X M O N T H S O F L I F E
iv

v
R E F E R E N C E S
Abbreviations & acronyms
AI Adequate intake
BMD Bone mineral density
BMC Bone mineral content
CDC Centers for Disease Control and Prevention (USA)
DPT Triple vaccine against diphtheria, pertussis and tetanus
DXA Dual-energy X-ray absorptiometry
EAR Estimated average requirement
EAST Erythrocyte aspartate transaminase
EPLP Erythrocyte pyridoxal phosphate
ESPGAN European Society of Paediatric Gastroenterology
FAO Food and Agriculture Organization of the United Nations
IDECG International Dietary Energy Consultative Group
IU International units
NCHS National Center for Health Statistics (USA)
NPN Non-protein nitrogen
PLP Pyridoxal phosphate
PMP Pyridoxamine phosphate
PNP Pyridoxine phosphate
PTH Parathyroid hormone
RE Retinol equivalents
SD Standard deviation
SDS Standard deviation score
UNICEF United Nations Children’s Fund
UNU United Nations University
WHO World Health Organization

Foreword
vii
R E F E R E N C E S
This review, which was prepared as part of the back-
ground documentation for a WHO expert consultation,1
evaluates the nutrient adequacy of exclusive breast-
feeding for term infants during the first 6 months of
life. Nutrient intakes provided by human milk are
compared with infant nutrient requirements. To avoid
circular arguments, biochemical and physiological
methods, independent of human milk, are used to define
these requirements.
The review focuses on human-milk nutrients, which
may become growth limiting, and on nutrients for which
there is a high prevalence of maternal dietary deficiency
in some parts of the world; it assesses the adequacy of
energy, protein, calcium, iron, zinc, and vitamins A,
B6, and D. This task is confounded by the fact that the
physiological needs for vitamins A and D, iron, zinc –
and possibly other nutrients – are met by the combined
availability of nutrients in human milk and endogenous
nutrient stores.
In evaluating the nutrient adequacy of exclusive breast-
feeding, infant nutrient requirements are assessed in
terms of relevant functional outcomes. Nutrient
adequacy is most commonly evaluated in terms of
growth, but other functional outcomes, e.g. immune
response and neurodevelopment, are also considered to
the extent that available data permit.
This review is limited to the nutrient needs of infants.
It does not evaluate functional outcomes that depend
on other bioactive factors in human milk, or behaviours
and practices that are inseparable from breastfeeding,
nor does it consider consequences for mothers. In
determining the optimal duration of exclusive breast-
feeding in specific contexts, it is important that func-
tional outcomes, e.g. infant morbidity and mortality,
also are taken into consideration.
The authors would like to thank the World Health
Organization for the opportunity to participate in
the expert consultation;1
and Nancy Krebs, Kim
Michaelson, Sean Lynch, Donald McCormick, Paul
Pencharz, Mary Frances Picciano, Ann Prentice, Bonny
Specker and Barbara Underwood for reviewing the draft
manuscript. They also express special appreciation for
the financial support provided by the United Nations
University.
1
Expert consultation on the optimal duration of exclusive
breastfeeding, Geneva, World Health Organization, 28–30 March
2001.

1
Executive summary
The dual dependency on exogenous dietary sources and
endogenous stores to meet requirements needs to be
borne in mind particularly when assessing the adequacy
of iron and zinc in human milk. Human milk, which is a
poor source of iron and zinc, cannot be altered by
maternal supplementation with these two nutrients. It
is clear that the estimated iron requirements of infants
cannot be met by human milk alone at any stage of
infancy. The iron endowment at birth meets the iron
needs of the breastfed infant in the first half of infancy,
i.e. 0 to 6 months. If an exogenous source of iron is not
provided, exclusively breastfed infants are at risk of
becoming iron deficient during the second half of
infancy. Net zinc absorption from human milk falls short
of zinc needs, which appear to be subsidized by prenatal
stores.
In the absence of studies specifically designed to evaluate
the time at which prenatal stores become depleted,
circumstantial evidence has to be used. Available
evidence suggests that the older the exclusively breastfed
infant the greater the risk of specific nutrient
deficiencies.
The inability to estimate the proportion of exclusively
breastfed infants at risk of specific deficiencies is a major
drawback in terms of developing appropriate public
health policies. Conventional methodologies require
that a nutrient’s average dietary requirement and its
distribution are known along with the mean and
distribution of intakes and endogenous stores.
Moreover, exclusive breastfeeding at 6 months is not a
common practice in developed countries, and it is rarer
still in developing countries. There is a serious lack of
measurement, which impedes evaluation, of the human-
milk intakes of 6-month-old exclusively breastfed
infants from developing countries. The marked attrition
rates in exclusive breastfeeding through 6 months
postpartum, even among women who are both well
nourished and highly motivated, is a major gap in our
understanding of the biological, cultural and social
determinants of the duration of exclusive breastfeeding.
A limitation to promoting exclusive breastfeeding for
the first 6 months of life is our lack of understanding of
the reasons for the attrition rates. Improved
understanding of the biological, socioeconomic and
E X E C U T I V E S U M M A R Y
In this review nutrient adequacy of exclusive
breastfeeding is most commonly evaluated in terms of
growth. Other functional outcomes, e.g. immune
response and neurodevelopment, are considered when
data are available. The dual dependency on exogenous
dietary sources and endogenous stores for meeting
requirements is also considered in evaluating human
milk’s nutrient adequacy. When evaluating the nutrient
adequacy of human milk, it is essential to recognize the
incomplete knowledge of infant nutrient requirements
in terms of relevant functional outcomes. Particularly
evident is the inadequacy of crucial data for evaluating
the nutrient adequacy of exclusive breastfeeding for the
first 4 to 6 months.
Mean intakes of human milk provide sufficient energy
and protein to meet mean requirements during the first
6 months of infancy. Since infant growth potential
drives milk production, the distribution of intakes likely
matches the distribution of energy and protein
requirements.
The adequacy of vitamin A and vitamin B6 in human
milk is highly dependent upon maternal diet and
nutritional status. In well-nourished populations the
amounts of vitamins A and B6 in human milk are
adequate to meet the requirements for infants during
the first 6 months of life. In populations deficient in
vitamins A and B6, the amount of these vitamins in
human milk will be sub-optimal and corrective measures
are called for, either through maternal and/or infant
supplementation, or complementary feeding for infants.
The vitamin D content of human milk is insufficient to
meet infant requirements. Infants depend on sunlight
exposure or exogenous intakes of vitamin D; if these
are inadequate, the risk of vitamin D deficiency rises
with age as stores become depleted in the exclusively
breastfed infant.
The calcium content of human milk is fairly constant
throughout lactation and is not influenced by maternal
diet. Based on the estimated calcium intakes of
exclusively breastfed infants and an estimated
absorption efficiency of > 70%, human milk meets the
calcium requirements of infants during the first
6 months of life.

N U T R I E N T A D E Q U A C Y O F E X C L U S I V E B R E A S T F E E D I N G F O R T H E T E R M I N F A N T D U R I N G T H E F I R S T S I X M O N T H S O F L I F E
2
cultural factors influencing the timing of supplemen-
tation of the breastfed infant’s diet is an important part
of advocating a globally uniform infant-feeding policy
that accurately weighs both this policy’s benefits and
possible negative outcomes.
It is important to recognize that this review is limited
to the nutrient needs of infants. No attempt has been
made to evaluate functional outcomes that depend on
other bioactive factors in human milk, or behaviours
and practices that are inseparable from breastfeeding.
Neither have the consequences, positive or negative,
for mothers been considered. It is important that
functional outcomes, e.g. infant morbidity and mortality,
be taken carefully into account in determining the
optimal duration of exclusive breastfeeding in specific
environments.
This review was prepared parallel to, but separate from,
a systematic review of the scientific literature on the
optimal duration of exclusive breastfeeding.1
These
assessments served as the basis for discussion during an
expert consultation (Geneva, 28–30 March 2001),
whose report is found elsewhere.2
1
Kramer MS, Kakuma R. The optimal duration of exclusive
breastfeeding: a systematic review. Geneva, World Health
Organization, document WHO/NHD/01.08–WHO/FCH/CAH/
01.23, 2001.
2
The optimal duration of exclusive breastfeeding: report of an expert
consultation. Geneva, World Health Organization, document
WHO/NHD/01.09–WHO/FCH/CAH/01.24, 2001.

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