Chapter 2: Provide nutrition in lactation

Nutrition during lactation is a critical aspect of maternal and child health, especially in Kenya where maternal and infant nutrition directly influences public health outcomes and economic productivity. Lactating women require adequate nutrients not only to support their own health but also to ensure the quality and quantity of breast milk, which is the primary source of nutrition for infants in the first six months. Nutrition and Dietetics professionals play a vital role in assessing and guiding mothers on how to meet these increased nutritional demands through diet, supplementation, and lifestyle adjustments. This chapter explores the nutritional needs in lactation, highlighting their importance and methods of nutritional assessment in lactating mothers.

2.1 Nutritional needs in lactation

Lactation is the period in which a mother feeds her baby with her own milk. For the first six months milk is the infant's complete food, and the mother must produce it while also recovering from birth and carrying out her daily work. This topic describes how the body makes milk, why the mother's nutrition matters for both of them, and how a dietitian assesses a breastfeeding mother's needs for energy, nutrients and fluid, using body measurements, laboratory tests, clinical signs and diet history.

2.1.1 Introduction to nutrition in lactation

Nutrition in lactation means the food, nutrients and fluid a mother needs to produce enough milk of good quality while keeping her own health. How much milk she makes depends mainly on how often and how well the baby feeds and empties the breast. Her diet decides how much of her own body stores are drawn on, and it changes the amount of some nutrients in the milk. A dietitian therefore looks at her meals, her stores, her workload and her feeding pattern together.

Exclusive breastfeeding is recommended for the first six months, and breastfeeding continues alongside other foods for two years or beyond. Many mothers meet the extra demand with ordinary household foods. Others have limited variety, long working hours, repeated infections or little time to eat, and these mothers are the ones who need early support.

Physiological changes during lactation

After delivery, falling progesterone and rising prolactin start milk production. Prolactin drives milk synthesis in the breast cells after each feed, and oxytocin makes the milk flow when the baby suckles or the mother hears or thinks of the baby. The more often milk is removed, the more milk the breasts make. Making milk uses energy, so appetite and thirst usually rise. When food intake is too low, the body draws on fat laid down in pregnancy and, for some nutrients, on the mother's own tissues.

Stages of breast milk

Breast milk changes with time. Colostrum, produced in the first days, is thick and yellowish, small in volume and rich in antibodies. Transitional milk follows during the first one to two weeks, and mature milk after that. Mature milk contains water, lactose, fat, protein, vitamins, minerals and protective factors such as antibodies and enzymes. Its energy comes largely from fat and lactose.

How the mother's diet and the milk are linked

The milk of a mother with a poor diet usually still contains enough protein, lactose, calcium, iron and folate, because her own stores make up the difference. Other components follow her intake, including the fatty acid pattern, iodine, vitamin A and several B vitamins. These are discussed under Micronutrients influencing milk quality. The practical rule is that a poor diet first costs the mother her reserves, and then, for the nutrients that follow her diet, reduces what the baby receives.

2.1.2 Importance of nutrition in lactation

Good nutrition in lactation protects two people at once. It supports the supply and content of the milk for the infant, and it helps the mother recover, keep her strength and avoid deficiencies.

Maternal health and recovery

Eating enough helps the uterus and any wounds to heal, and it replaces the iron, protein and other nutrients lost in pregnancy and delivery. A mother who is underfed may lose weight too quickly, become tired and anaemic, and lose bone mineral for a time. She also needs energy for night feeds and household tasks, and a well-fed mother is better able to breastfeed often.

Infant growth and development

For the first six months breast milk supplies the infant's energy, fluid and most nutrients. A mother whose diet is varied and who drinks enough supports her infant's growth, brain development and defences against infection. The infant of an undernourished mother may still thrive on her milk, but the mother pays for it with her own reserves.

Immune protection

Breast milk carries antibodies, white cells and other protective factors that lower the infant's risk of diarrhoea, chest infections and ear infections. The mother's diet influences some of these through the nutrients involved in immunity. For example, a mother with low vitamin A stores secretes less vitamin A in her milk, and an infant who receives less vitamin A is at greater risk of severe infections.

Impact on long-term health

Breastfeeding supported by good maternal nutrition is linked with a lower risk of overweight in the child. In the mother, breastfeeding is linked with a lower risk of type 2 diabetes and of some cancers. Because the same links are seen across many studies, dietitians promote breastfeeding together with sound maternal nutrition.

Socioeconomic and cultural factors

Beliefs about foods after childbirth, who cooks, how much money the household spends on food and whether the mother returns early to farm or market work all affect what she eats. Some families offer nourishing foods such as porridge, soup and milk, and others discourage certain foods. A dietitian respects practices that help and discusses gently those that limit useful foods, working with the family and not against it.

2.1.3 Assessment of nutritional needs in lactation

Assessment finds out whether a breastfeeding mother is meeting her needs and, if not, why. A dietitian combines four sets of evidence: body measurements, laboratory tests, clinical signs and diet history. In lactation the dietitian also notes the stage of lactation, how often the baby feeds and whether the baby is growing well, because the infant's growth is a sign of how feeding is going. The mother is told what each step is for, her consent is obtained, findings are written in her record, and problems outside the dietitian's scope go to the clinician.

Socioeconomic and environmental assessment

A mother's circumstances shape her intake and are part of the assessment. A dietitian asks about:

• Food security: whether the household has enough meals and whether variety falls in the dry season or before harvest.
• Workload: whether she farms, trades or works away from the baby, and when she can eat, drink and feed.
• Household support: who cooks, who minds the baby and who decides how food money is spent.
• Water and sanitation: whether clean water for drinking and for washing hands is available.
• Health factors: HIV status and treatment, other long-term illness, family planning use and alcohol use.
• Beliefs and customs: food customs and restrictions after childbirth.

2.1.3.1 Anthropometry

Anthropometry is the measurement of the body to judge nutritional status. In lactation the dietitian measures weight, height, body mass index (BMI) and mid-upper arm circumference (MUAC) with calibrated equipment, using the same method at every visit. Weight is taken in light clothing without shoes. MUAC is taken on the left arm, midway between the shoulder tip and the elbow.

Body mass index is weight in kilograms divided by height in metres squared. For adult women, a BMI below 18.5 kg/m² means underweight, 18.5 to 24.9 is the healthy range, 25.0 to 29.9 is overweight and 30.0 or more is obese. A low BMI in a breastfeeding mother signals low reserves and a risk to her health, though milk volume is often maintained at the cost of her stores. A MUAC below 23 cm is used in many programmes to pick out pregnant and breastfeeding women who may be acutely malnourished, and the cut-off in the facility's current national guideline is the one applied.

Worked example: a breastfeeding woman who is 1.60 m tall weighs 45 kg at the child welfare clinic. Height squared is 1.60 × 1.60 = 2.56. BMI = 45 ÷ 2.56 = 17.58, so about 17.6 kg/m². This is below 18.5, so she is underweight. The dietitian asks about meals, illness and workload, checks her haemoglobin through the clinician and plans extra meals and snacks with her. Weight is checked at every visit.

After birth many women keep some of the weight gained in pregnancy. Slow, gradual loss while breastfeeding with regular meals is safe. Crash dieting is not advised, because it reduces both her energy and nutrient intake.

2.1.3.2 Biochemical assessments

Biochemical assessments are laboratory tests that show whether the mother's stores and body functions are adequate. They are requested through the clinician or within the facility's protocol, and they back up what the other methods suggest.

• Haemoglobin: a breastfeeding woman is anaemic when haemoglobin is below 12.0 g/dL. Mild anaemia is 11.0 to 11.9 g/dL, moderate is 8.0 to 10.9 g/dL and severe is below 8.0 g/dL.
• Serum ferritin: low values show depleted iron stores, sometimes before haemoglobin falls.
• Blood glucose: a woman who had diabetes in pregnancy is tested after delivery as the clinician directs.
• Vitamin B12, vitamin D and folate levels: requested when deficiency is suspected, for example in a woman who eats no animal-source foods.
• Urinary iodine: used in surveys to judge iodine intake of groups of lactating women. It is not used to diagnose one woman, because a single sample varies from day to day.

Blood is taken with a single-use lancet or needle, which goes straight into a sharps container. Lancets are never cleaned or reused.

2.1.3.3 Clinical monitoring

Clinical monitoring means looking at the mother's body and health for signs of poor nutrition and for problems after birth that affect eating. WHO advises postnatal contact within the first 24 hours, around day 3, between days 7 and 14, and at six weeks, and the dietitian works with the midwife or nurse at these contacts.

• Pallor: pale palms, tongue or inner eyelids suggest anaemia, often after bleeding at delivery.
• Wound healing: slow healing of a caesarean or perineal wound can point to poor protein, vitamin C or zinc intake, or to infection, which is referred.
• Hair, skin and mouth: thin dry hair, dry flaking skin, cracks at the corners of the mouth or a smooth sore tongue can accompany poor intake of protein and some vitamins.
• Blood pressure, fever, heavy bleeding or severe pain: referred to the clinician at once.
• Mood: persistent sadness, worry or loss of interest is referred to the clinician or counsellor, because low mood reduces eating and feeding.
• Breasts and feeding: a sore breast, a hard red area or a baby who attaches poorly is referred for feeding support.

A dietitian does not treat infections or wounds. Findings are shared with the clinician and entered in the nutrition record.

2.1.3.4 Dietary assessments

Dietary assessment finds out what the mother eats and drinks and how it compares with her needs. Methods include the 24-hour recall, in which she lists everything taken in the last day and night; the food frequency questionnaire, which asks how often she eats key foods; the food diary, kept for several days; and a dietary diversity score. The women's dietary diversity score counts how many of ten food groups she ate in the last day, and five or more groups is taken as a minimum level of variety. The dietitian also asks how often the baby feeds, whether the mother skips meals when busy and whether she eats at night.

Worked example: a mother reports millet uji with milk and a boiled egg at breakfast, rice with green grams at lunch, and ugali with sukuma wiki and omena at supper. The groups present are grains, dairy, eggs, pulses, dark green leafy vegetables and fish, which makes six, so she meets the minimum of five. There is no vitamin A-rich fruit or vegetable and no fruit, so the dietitian suggests ripe mango, pawpaw or pumpkin when in season.

Intake is then compared with the reference values for lactation described in the sub-items below. These are planning figures for healthy groups, used as a guide with the mother's own situation.

2.1.3.4.1 Energy requirements

Making milk costs energy. Breast milk contains about 65 to 70 kcal per 100 mL. A mother who makes 750 mL a day secretes 750 ÷ 100 × 65 = 487.5 kcal at the lower value and 750 ÷ 100 × 70 = 525 kcal at the higher value, so about 490 to 525 kcal a day. The body does not turn food into milk with full efficiency, and part of the cost is met from fat stored in pregnancy.

The joint FAO, WHO and UNU consultation estimates an additional 505 kcal a day for the first six months for a well-nourished mother who gained a healthy amount of weight in pregnancy. The Institute of Medicine of the United States uses a smaller increase of 330 kcal a day for the first six months and 400 kcal a day for the second six months, because fat stores are being used. After six months, when the baby takes other foods, milk volume and the extra need begin to fall.

Worked example: the energy need of a mother before pregnancy was 1,900 kcal a day. With the FAO, WHO and UNU estimate the planning figure for the first six months is 1,900 + 505 = 2,405 kcal a day. With the Institute of Medicine estimate it is 1,900 + 330 = 2,230 kcal a day. The starting figure is hypothetical. Advice is to eat to appetite, adding two snacks and a larger portion at the main meals. A mother who gained little in pregnancy has fewer stores and needs more from food than one who gained well.

2.1.3.4.2 Macronutrients

Macronutrients are protein, carbohydrate and fat, together with fibre. Protein needs rise because milk contains protein and the mother needs it for recovery. FAO, WHO and UNU give an additional 19 g a day in the first six months and about 12.5 g a day after that. Good sources are beans, cowpeas, green grams, eggs, fish, milk, groundnuts, meat and poultry.

Carbohydrate supplies the energy for making milk. The recommended intake in lactation is 210 g a day. Staples such as ugali, rice, sweet potato, cassava, arrowroot and green banana provide it, and wholegrain forms add fibre and B vitamins. Fat supplies energy and the fatty acids that build the baby's brain and eyes. The fat in the milk follows the types the mother eats, so fish, groundnuts, avocado and vegetable oils are encouraged, while deep-fried snacks are limited. Fibre of about 29 g a day from wholegrains, pulses, vegetables and fruit helps to prevent constipation after birth.

2.1.3.4.3 Iron

The iron content of breast milk is low and does not rise much with the mother's intake. Iron is assessed in lactation for the mother's own sake. Blood lost at delivery, low stores before pregnancy and an early return of periods can leave her anaemic. Her recommended intake in lactation is about 9 mg a day for an adult woman, lower than in pregnancy because periods are usually absent during exclusive breastfeeding.

The dietitian checks haemoglobin, asks about heavy bleeding and the foods eaten, and encourages liver, meat, small fish eaten with the bones, beans and dark green leafy vegetables, together with a vitamin C-rich fruit. Tea and coffee are taken between meals and not with them, because they reduce iron absorption. Iron and folic acid supplements continue after birth for the period set by the national guideline, and the clinician decides on treatment for anaemia.

2.1.3.4.4 Iodine

An exclusively breastfed baby gets iodine only from milk, and the iodine in milk follows the mother's intake. WHO recommends 250 µg of iodine a day for breastfeeding women. Low iodine in milk can affect the baby's brain development.

Iodised salt is the practical source, together with fish, milk and eggs. Salt is stored in a covered container away from heat and damp and is added toward the end of cooking, because iodine is lost on long heating. A mother should not take large amounts of iodine from supplements such as kelp, because too much disturbs the thyroid. The dietitian asks whether the household's salt is iodised.

2.1.3.4.5 Vitamin D

Vitamin D helps the gut absorb calcium and builds bone. The recommended intake in lactation is 15 µg (600 IU) a day. Breast milk contains only a small amount of vitamin D unless the mother's own level is good, so the baby's vitamin D comes mainly from sunlight on the baby's skin and, where the clinician advises, a supplement for the baby.

The mother makes vitamin D in her own skin when her face and arms are exposed to sunshine for short periods. How much she makes depends on skin tone, clothing and time outdoors. Foods that help are oily fish, egg yolk and fortified products. A mother who stays indoors for weeks after birth, as some customs encourage, is at greater risk of a low level, so the dietitian discusses time outdoors with the family.

2.1.3.4.6 Folic Acid

Folate is needed to form blood cells and, before and early in pregnancy, to protect the baby from neural tube defects. Breast milk keeps its folate content even when the mother's stores are low, so her own stores can be drawn down. The recommended intake in lactation is 500 µg of dietary folate equivalents a day.

Good sources are dark green leafy vegetables, beans, cowpeas, liver, oranges and fortified flours. Folate is lost in long cooking, so vegetables are cooked briefly. A woman who may conceive again soon is counselled on family planning and, where advised, on a folic acid supplement, because a pregnancy that starts with low folate carries a higher risk of a neural tube defect.

2.1.3.4.7 Zinc

Zinc is needed for the mother's healing, immunity and appetite, and for making milk. The recommended intake in lactation is 12 mg a day for adult women. The zinc content of milk falls gradually over the months of lactation whatever the mother eats, so the dietitian's aim is to protect her own zinc stores.

Sources are meat, fish, eggs, milk, beans, groundnuts and pumpkin seeds. In diets based on unrefined maize, sorghum or millet, phytates in the grain reduce zinc absorption, and soaking, fermenting and germinating the grain help. Zinc supplements are given on the clinician's advice, because high doses interfere with copper.

2.1.3.4.8 Micronutrients influencing milk quality

Some micronutrients in breast milk rise and fall with the mother's intake, so her diet affects what the baby receives. These need particular attention in assessment.

A mother who eats no animal-source foods needs a vitamin B12 supplement on the clinician's advice. High doses of ready-made vitamin A are not given without clinical advice, because too much is harmful to the baby, and WHO does not recommend routine vitamin A supplements for every mother after delivery.

2.1.3.4.9 Increased Fluid Needs

Breast milk is about 87% water, so a breastfeeding mother loses fluid each day through her milk and needs to replace it. The Institute of Medicine sets the adequate intake of total water for lactating women at 3.8 litres a day, of which about 3.1 litres comes from drinks and the rest from food.

A practical guide is thirst together with pale yellow urine. Many mothers feel thirsty during feeds, so a cup of water placed within reach before each feed is helpful. Suitable fluids are clean boiled or treated water, uji, soup and milk, with sugary drinks and heavy tea or coffee kept to small amounts. Drinking far more than thirst asks for does not raise milk supply. Dark urine, headache, dry lips and constipation are signs that she needs more fluid.

Chapter Summary

This chapter provides a comprehensive overview of nutrition during lactation, beginning with the increased nutritional needs that support both mother and infant health. It highlights the significance of adequate nutrition in lactation and outlines methods for assessing these needs through anthropometry, biochemical tests, clinical monitoring, and dietary evaluations. The chapter then examines common breastfeeding complications such as sore nipples, engorgement, mastitis, and nipple abnormalities, emphasizing their impact on successful breastfeeding. An introduction to nutrition interventions follows, detailing the development of nutrition plans and the various intervention types including supplementation, diet planning, deworming, and education. Practical guidance on carrying out nutrition interventions is provided, focusing on implementation steps and the necessary tools and resources. Finally, the chapter discusses the importance of monitoring and evaluating nutrition interventions, describing assessment techniques, indicators of success, and the challenges encountered in ensuring effective nutrition support during lactation.