lactation

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Breast-feeding After Bariatric Surgery

By Stefanski, RD, LDN, CDE

Today's Dietitian

Vol. 8 No. 1 P. 47

Lactating mothers and their infants have special nutrition needs.

Can women with limited food intake after bariatric surgery meet

those needs?

An outpatient dietitian at Bellevue Woman's Hospital in Niskayuna,

N.Y., Karann Durr, RD, CDN, searched the Internet, consulted

personal resources, and contacted other RDs for advice and

information. She was left with nothing substantial. In the end, she

and her hospital's lactation consultant were forced to make

professional guesses on the issue—lactation after gastric bypass

surgery.

Durr explained, " I had to take the evidenced-based practice

guidelines for lactation and the nutrient recommendations for

gastric bypass and put the two together. Basically, because this is

new, people are reluctant to venture there. "

The human body can adapt to the changing demands of lactation by

increasing nutrient intake, improving absorption, decreasing

excretion, or using tissue stores. For the patient who has undergone

bariatric surgery, it is questionable whether the body's natural

adaptations for lactation can overcome the physiological changes the

surgery has created.

According to Jeanne Blankenship, MS, RD, an expert in bariatric

surgery and reproductive health from the University of California,

Medical Center, " We need to promote breast-feeding to this

population—more than 80% of the women who have surgery are of child-

bearing age. The numbers are going to keep going up. "

Blankenship further elaborates that " we do know that obese women are

less likely to initiate breast-feeding and, if they do, they are

less likely to make it to the major marks—three and then six months—

let alone one year. What we don't know is if a woman who was

previously obese behaves like an obese woman or like a normal-weight

woman in terms of lactation. There are definitely success stories,

but I think a lot of these women fall through the cracks. "

Gail Hertz, MD, IBCLC, pediatrician and certified lactation

consultant, points out that not all healthcare practitioners may be

familiar with the long-term effects of bariatric surgery. " The

average pediatrician probably isn't aware of the impact of gastric

bypass on nutrition because typically our patients aren't undergoing

the procedure themselves. In our practice, we do ask breast-feeding

mothers about any breast reconstruction or reduction, but if the

mother doesn't volunteer information about her past surgeries, we

may not know. "

Surgical Ramifications

Weight-reduction surgeries are classified as restrictive,

malabsorptive, or a combination of the two. Operations such as

vertical banded gastroplasty (VBG) and gastric banding aim to limit

the amount of food that can be ingested and reduce the emptying rate

of the stomach.

The Roux-en-Y gastric bypass (RYGB), bilio-pancreatic diversion

(BPD), and the now uncommon jejuno-ilial bypass combine restriction

and malabsorption. The RYGB utilizes a 30- to 50-milliliter pouch,

formed by surgically separating the stomach. A gastrojejunostomy is

created by anastomosing the stomach to the distal end of the

jejunum.1

The BPD utilizes a subtotal gastrectomy to create a larger pouch

than the VBG or RYGB. As a more complicated surgery, the small

intestine is divided to create a gastroileostomy, bypassing the

lower stomach, duodenum, and jejunum and leaving only the distal

ileum for nutrient absorption.2

Due to the surgical alteration of the gastrointestinal tract using

the RYGB and BPD approaches, patients require perpetual

supplementation to meet minimal nutrient needs. If eating habits are

too restrictive after VBG or laparoscopic banding, deficiencies may

occur.3

Habits Under Investigation

Conduct a survey of bariatric practitioners and you will find varied

vitamin and mineral prescriptions. In terms of pregnancy and

lactation, the general nutrient recommendations may not meet

increased requirements. Additionally, compliance with recommended

supplements can be poor.4,5

Total weight loss averages 25% to 35% of initial body weight at 18

months after surgery.6,7 Pregnancy is not recommended within the

first 18 to 24 months after surgery due to the active weight loss

occurring. After 24 months, weight loss has stabilized or regain may

begin to occur. Several articles have been published that address

the needs of pregnancy after gastric bypass.8-12

Calorie consumption has been shown to be approximately 1,100

calories per day at one year post-op and 1,300 calories per day at

18 months.13 Post-gastric bypass patients' diets have also been

shown to be low in nutrients vital to pregnancy and lactation, such

as iron, calcium, and folate.14 Actual vitamin deficiencies, other

than vitamin B12 and folate, have yet to be quantified.15

Due to the absence of standardized follow-up of patients after

surgery, there is inadequate information regarding the effects of

bariatric surgery on many aspects of health.3 Women who have

achieved healthy pregnancies face challenges when it comes to breast-

feeding. Limited data exists to help practitioners guide mothers in

the right direction.

Will the Maternal Diet Affect Milk Production?

Human milk is a symphony of nutrients that varies between mothers

and changes with lactation duration or even time of day.16 In

studies of lactation during famine conditions, malnourished mothers

were able to produce sufficient breast milk and support normal

growth in their infants.17,18 In several instances, maternal

nutrition stores suffered as breast milk quantity and quality

remained adequate.17,19

" It is definitely true that there is no reason that they can't

breast-feed if their diet is adequate. Compliance with vitamins and

minerals is important. It really depends on the type of surgery, how

long it has been since surgery combined with their breast-feeding

history, age, and, of course, all the factors that affect breast-

feeding in the general population, " explains Blankenship. When

combining breast-feeding with a history of bariatric surgery, there

are several key nutrients practitioners must focus on to achieve

success in the breast-feeding relationship.

Calories

For lactation, the dietary reference intake is 500 calories higher

than guidelines intended for women who are not breast-feeding. This

recommendation of 2,700 calories per day is based on energy needed

for milk production, energy mobilized from fat stores, and estimated

metabolic rate. It is assumed that 66% of calorie needs will be

provided by oral intake and 34% will come from fat stores gained

during pregnancy.20

In one study, participants consumed approximately 1,500 calories per

day for the first six months of lactation. Although these women had

not undergone weight-loss surgery, their low calorie intake did not

affect breast milk production and prolactin levels remained within

normal limits.21

Vitamin B12

Several important steps in vitamin B12 absorption are affected by

RYGB. Deficiencies have been discovered in 30% to 70% of patients

one to nine years after RYGB.22-25 Hemoglobin or mean corpuscular

volume levels may not reveal this deficiency.26

Secretion of hydrochloric acid may be nearly absent in the

surgically created pouch.27 With decreased acid and pepsin exposure,

vitamin B12 can not be cleaved from foods such as meat, milk, and

eggs. B12's attachment to glycoproteins and subsequent coupling with

intrinsic factor is also hindered by the pathophysiology of the

RYGB.6,28

Mothers who are B12 deficient during pregnancy may give birth to

infants with subnormal B12 stores. Further depletion may occur as

the infant is undersupplied via human milk from a B12 deficient

mother.29

In a case study presented in 1994, a 10-month-old, exclusively

breast-fed infant was found to have a vitamin B12 deficiency. Two

years prior, the mother had undergone bariatric surgery. Although

the mother was asymptomatic, she was also deficient in vitamin B12.30

In a similar scenario, a 12-month-old, exclusively breast-fed infant

of a semivegetarian mother, presented with developmental delay,

macrocytic anemia, low folate and B12 levels, a positive urinary

methylmalonic acid peak, and a high homocystine level. The infant's

B12 deficiency was corrected parenterally. Two months later, the

mother revealed she had undergone bariatric surgery six years

earlier. Although the mother consumed vitamin B12 and iron

supplements, the vitamin B12 level of her milk was found to contain

only 42 picomoles per liter compared with a normal level of 184 to

812 picomoles per liter.31

Folate

Absorbed primarily by the proximal one third of the small intestine,

folate absorption must now occur in a smaller surface area under

modified conditions. Folate deficiency has been documented in up to

40% of patients after RYGB and is of great concern in regard to the

onset of neural tube defects. Both serum folate levels and red blood

cell counts should be evaluated to detect deficiencies and patients

supplemented appropriately.3,23,32

Calcium

Due to the circumvention of the duodenum in RYGB, the primary

absorption site for calcium is omitted. Passive diffusion of calcium

must occur along the remaining small intestine. Serum levels may

remain stable, as calcium is leeched from maternal stores.6

Reductions in maternal bone content occur during the first three to

six months of lactation, but this loss is replaced in later

lactation and after weaning.33

Breast milk calcium secretion does not appear to depend on the

current calcium intake of the mother, nor does the intake of

phosphorus, magnesium, or sodium. Maternal intake during pregnancy

may predetermine the calcium content of breast milk after

delivery.33-35

Vitamin D

The ideal amount of calcium and vitamin D gastric bypass patients

need to maintain stable parathyroid hormone and 25-hydroxyvitamin D

has yet to be determined. Typical amounts of 800 to 1,000

international units (IUs) are provided upon initiation.36,37,3

Infants may be influenced more by the vitamin D status of the mother

during pregnancy and by the amount of sun exposure received rather

than by vitamin D levels in breast milk. Human milk naturally

contains low levels of vitamin D. Additionally, there is little

evidence to suggest that lactation increases vitamin D needs in the

mother.38-40

Guidelines have previously encouraged two hours per week of direct

sun exposure or 30 minutes per week wearing only a diaper to

stimulate adequate vitamin D production in the exclusively breast-

fed infant.41 The American Academy of Pediatrics now recommends that

infants less than 6 months old be kept out of direct sunlight to

limit UVA light exposure and suggests that " all breast-fed infants

receive at least 200 IU of vitamin D per day beginning in the first

two months after delivery. " 42

Iron

Decreased intake of sufficient sources of heme iron, a reduction in

the acidic environment required to release heme iron, and changes in

absorptive surface area impact iron stores.3,6 Iron deficiency may

occur in up to 50% of patients after RYGB, especially in women who

are still menstruating.6,22-26 Amenorrhea from sustained lactation

can actually benefit women as decreased blood loss via the menstrual

cycle can boost depleted iron stores.42

Although breast milk is a poor iron source, iron from human milk is

better absorbed than formula.43 Lactoferrin, a whey protein

connected with infant immune response, has been found in greater

concentration in breast milk from iron-deficient women. It has been

hypothesized that this increase may help protect the infant from

iron deficiency.44-46

Some evidence suggests that standard multivitamins will not prevent

a deficiency after bariatric surgery.13,22,23,25 Women who have

undergone restrictive procedures may not require additional iron

beyond the standard recommendations.47

Fat-Soluble Vitamins

Vitamin A deficiencies have only been reported to occur after

biliopancreatic diversion in the nonpregnant population.15 Vitamin A

levels should be tested early in pregnancy and patients should be

counseled to consume adequate amounts of vitamin A via food. Women

who oversupplement may be at risk of consuming intakes of preformed

vitamin A in amounts greater than 5,000 IUs, which may cause birth

defects.37 Fat-soluble vitamin content of breast milk has been found

to be minimally impacted by recent intake of the mother.17

Water-Soluble Vitamins

Maintenance of adequate water-soluble vitamin levels in the body,

especially thiamine, requires a continuous supply in the diet. Even

patients who have undergone restrictive procedures can develop a

deficiency if oral intake is inadequate.12,48,49

Vitamin C, niacin, thiamine, riboflavin, and vitamin B6 levels in

human milk are greatly influenced by the mother's diet. In studies

of maternal supplementation of water-soluble vitamins, vitamin

levels increased in human milk and then leveled off.17 High doses of

vitamin B6 should be avoided as production of prolactin may be

inhibited.50

Protein

No consensus has been reached on the extent to which protein energy

malnutrition may develop after gastric bypass surgery. A protein

intake of 65 grams per day is recommended for the first six months

of breast-feeding.17 Patients' diets and lab values should be

evaluated, and patients should be encouraged to focus on high-

quality protein sources to meet minimal guidelines.51

According to O'Donnell, MS, RD, CNSD, nutrition support

specialist with the University of Virginia Medical Center, " Our

average patient, two to three years out, is consuming about 900 to

1,000 calories per day. Specific food choices are one of the most

essential points to stress. Snacks become very significant. Choosing

low fat, high protein choices, which are good calcium sources, are

very important. "

Fat

Lipid comprises one half of breast milk calories and is highly

variable.16,52,53 The total lipid content of human milk is not

affected by daily intake in normal mothers, although it has been

correlated with maternal fat stores.54

Breast milk contains arachidonic acid (ARA) and docosahexaenoic acid

(DHA), which have been associated with improved cognition, growth,

and vision in children.55 Some experts recommend supplementation of

ARA and DHA in the diets of both pregnant and lactating mothers,

especially for those with limited diets.

A patient who failed to follow nutrition guidelines provided after

her gastric bypass several years earlier suffered from anemia during

her pregnancy and gave birth to an infant weighing little more than

5 pounds. Growth milestones were not reached and, upon assessing the

mother's breast milk at four months postpartum, an analysis of the

fat content, or creamatocrit, revealed a low mean fat and calorie

content. After the mother supplemented with formula, adequate growth

was displayed in the infant at 6 months of age.56

Should We Wait for Weight Loss?

Exaggerated concern with reinitiating rapid weight loss after birth

may cause some women to forgo breast-feeding altogether. Blankenship

points out that there may be significant psychological issues to

consider. " Many pregnancies are unplanned and women just want to get

back to the weight loss. Patients have misconceptions about weight

loss during lactation and they want to be able to drastically cut

calories. "

Regardless of the fact that many studies have reviewed the impact of

lactation on weight maintenance, true consensus has not been

reached. Greater weight loss has been shown in breast-feeding

mothers vs. women who choose to use formula, while other studies

have been inconclusive.57-61

Gradual weight reduction, in amounts no greater than 1 pound per

week, does not appear to negatively affect the quantity or quality

of breast milk produced, though environmental pollutants stored in

maternal fat tissue may be released into breast milk with extended

weight loss.62,17

Vitamin and Mineral Supplements

Women of childbearing age should be advised to consume a prenatal

vitamin containing 1 milligram of folate, 350 to 500 micrograms of

crystalline vitamin B12, plus calcium citrate in amounts of 1,200 to

1,500 milligrams and vitamin D. Patients who have had gastric bypass

surgery should consume 40 to 65 milligrams iron in the ferrous form

daily.8,37 Some guidelines suggest that, during pregnancy, the

prenatal vitamin should be given in addition to, not instead of, a

daily multivitamin.10 The consumption of two prenatal vitamins may

not be advisable because some combinations may exceed vitamin A and

iron guidelines.37

Maternal lab values, including CBC, albumin, folate, vitamin B12,

calcium, phosphorus, and 25-dehydroxy-vitamin D, should be tested

during pregnancy and after birth to detect deficiencies and

supplemented accordingly. Infants should be evaluated for

appropriate growth, adequacy of B12, calcium, and folate levels

throughout the duration of breast-feeding.

Careful Monitoring Equals Success

Carla Woodard, MSN, WHNP, nurse practitioner with the University of

Tennessee Medical Center, emphasizes the importance of educating

both patients and practitioners. " The challenge for healthcare

providers lies in educating women pre- and post-operatively

regarding the ramifications of stopping vitamin supplements, which a

good number do. Lifelong B vitamin and calcium supplementation is a

must for these patients, especially those planning a pregnancy.

Pediatricians and pediatric nurse practitioners, as well as women's

healthcare providers, should also be made aware of these dangers. "

The increased risk of nutritional deficiencies induced by bariatric

surgery, coupled with the demands of lactation, requires careful

monitoring by knowledgeable professionals familiar with both

bariatric surgical procedures and the nutritional needs of lactating

mothers and their infants.

— Stefanski, RD, LDN, CDE, is a clinical dietitian, adjunct

professor, and freelance writer in York, Pa.

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56. Martens WS, LF, Berlin CM. Failure of a nursing infant to

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pregnancy. Int J Obes. 1990;14(2):159-173.

58. Greene GW, Smiciklas- H, Schol TO, et al. Postpartum

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59. Kac G, Benicio MH, Velasquez-Melendez G, et al. Breastfeeding

and postpartum weight retention in a cohort of Brazilian women. Am J

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60. Potter S, Hannum S, McFarlin B, et al. Does infant feeding

method influence maternal weight loss? J Am Diet Assoc. 1991;91:441-

446.

61. Dewey KG, McCrory MA. Effects of dieting and physical activity

on pregnancy and lactation. Am J Clin Nutr. 1994;59(suppl):446S-452S.

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840.

>

> Does anyone have experience with breast feeding after gastric

bypass?

>

[Guest guest]

Feel free to contact me if you have questions about lactation after gastric bypass, I have given a few presentations on this topic. My work phone is 530-754-5844.

Jeanne Blankenship, MS RD

[Guest guest]

Jeanne,

Could you send me those presentations via

email?

Janette RD, LD

Mercy Center for Weight Reduction

603 E 12th st

Des Moines, IA 50309

P 515-643-0532

F 515-643-0939

E jhoward@...

From:

[mailto: ]

On Behalf Of Jeanne Blankenship

Sent: Monday, December 04, 2006

8:16 AM

Subject:

Re: lactation

Feel free to contact me if you have questions about

lactation after gastric bypass, I have given a few presentations on this

topic. My work phone is 530-754-5844.

Jeanne Blankenship, MS RD

[Guest guest]

Thank you

From:

[mailto: ]

On Behalf Of Jeanne Blankenship

Sent: Monday, December 04, 2006

9:16 AM

Subject:

Re: lactation

Feel free to contact me if you have questions about

lactation after gastric bypass, I have given a few presentations on this

topic. My work phone is 530-754-5844.

Jeanne Blankenship, MS RD

[Guest guest]

I don't suppose you have any good resources for pregnancy and gastric

bypass. I have a gal who is 8 months from surgery and now 8 weeks

pregnant. She is coming into the office on Friday.

Hosier, RD, LD

Clinical Dietitian

Member ASBS www.asbs.org

St. Luke's Regional Medical Center

381-1519

>>> jbship@... 12/4/2006 7:15:40 AM >>>

Feel free to contact me if you have questions about lactation after

gastric bypass, I have given a few presentations on this topic. My work

phone is 530-754-5844.

Jeanne Blankenship, MS RD

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[Guest guest]

just wondering if the above is normal for age ( 36 )..get it slightly when

pressure applied to breats and sometimes get a slight leak after jogging or

aerobic exercise, is this a hypo symptom..?

Just wondering after chasing my tail with gyno and being told LH levels abnormal

by doc and then not by endo and gyn as oestrogen levels normal, which makes me

even more confused as I have read the more oestrogen you have is bad re thyroid

as act as a binder or am I barking ( yes well I think that's been

established!!!) up the wrong tree..??

thanks much

Jill

XX