November/December 2020 Issue
By Densie Webb, PhD, RD
Vol. 22, No. 9, P. 36
Research is scant on recommendations, but dietitians can counsel pregnant and breast-feeding moms effectively based on available guidelines.
Everyone knows a full-term pregnancy consists of three trimesters, and much attention and care is given to the health and nutrient intake of pregnant women during those nine months. Much less focus is placed on what the American College of Obstetricians and Gynecologists (ACOG) has dubbed the “fourth trimester”—the months following birth that often involve breast-feeding, sometimes the onset of depression, and healing and strength building.
According to ACOG, the weeks immediately following birth can set the stage for long-term health and well-being in mothers and infants alike.1
It’s common knowledge as well as common sense that a balanced, nutritious diet for women both during pregnancy and after delivery is best for both mother and baby. Prenatal vitamins are a universal recommendation for pregnant women to ensure nutrient intake if a woman’s diet falls short. But what about during the postpartum period? Many of the nutrients that are of particular concern during pregnancy remain important during the postpartum period, but simply following a well-balanced diet may not be enough for women during the so-called fourth trimester, especially for those who choose to breast-feed or who have experienced greater than average blood loss during delivery.
Little information is available on the potential benefits of supplementation during the postpartum period, aside from recommendations for breast-feeding, making it difficult to guide new mothers in their postbirth recovery.2 Existing recommendations for postpartum supplementation vary and some are even contradictory. For example, the Centers for Disease Control and Prevention recommend continuation of nutrient supplementation for mothers who breast-feed only if they follow restrictive diets, and they cite vegetarian diets as falling into that category.3
ACOG makes no definitive recommendations on how long prenatal supplements should be continued during the postpartum period or which vitamins should be supplemented or at what dose, while the World Health Organization recommends continuation of prenatal vitamins for at least three months postpartum, if anemia is a risk factor. Specifically, in areas where the prevalence of anemia in pregnant women is high (40% or more), the World Health Organization recommends women should routinely receive iron and folate supplements to prevent anemia.4
The different expert recommendations for supplementation in the postpartum period likely is due to the fact that the role of nutrition in maternal postpartum health hasn’t been well researched, especially when compared with prenatal health. However, several nutrients are critical during the postpartum period for women who are breast-feeding and for all women postpartum who are healing while caring for a newborn. A few studies have shed light on the subject, and there are experts who lend their knowledge and experience to the topic.2
“While breast-feeding is a major factor for changing nutrient requirements, it might come as a surprise that there are no separate official guidelines for non–breast-feeding women postpartum,” says Alexandra Paetow, MS, RD, CDN, owner of Thrive and Bloom Nutrition LLC, a private practice specializing in preconception, prenatal, and postpartum nutrition, based in Maplewood, New Jersey. “The healing that is required after childbirth is another important consideration.” Paetow recommends that women who aren’t breast-feeding continue a prenatal supplement for at least three months to cover any possible nutrient shortfalls.
“I would argue that vitamin and mineral needs do shift for all postpartum women, at least in the immediate postpartum period,” Paetow continues. She emphasizes that many women struggle with iron-deficiency anemia during pregnancy, and iron continues to be a concern during the postpartum period. “When the increased iron needs of pregnancy are compounded by blood loss postpartum,” Paetow says, “ensuring an iron-rich diet and supplementation as needed is an important nutritional focus in the postpartum period.”
According to Lily Nichols, RDN, CDE, author of Real Food for Pregnancy, the considerations for vitamin and mineral intake postpartum are two-fold: the mother’s recovery and well-being and the micronutrients in breastmilk for women who choose to breast-feed. Nichols says most of the women who reach out to her postpartum are concerned about eating for boosting milk supply, but aren’t necessarily thinking about postpartum recovery, a topic she devoted a chapter to in her book. Based on the physiology of postpartum recovery, including massive hormonal shifts, she says the focus should be on choline, iodine, iron, zinc, vitamin A, selenium, DHA, and vitamin B12 when counseling women postpartum.
Elizabeth Ward, MS, RD, author of Expect the Best: Your Guide to Healthy Eating Before, During, and After Pregnancy, says it’s important to remember that suggested intakes for several nutrients, including vitamins C and E, choline, and DHA are higher during breast-feeding than pregnancy. While the recommendations also are higher for vitamins A, C, and E, it’s typically easier to satisfy them through food or with a regular multivitamin.”
Nutrition for Women Who Breast-Feed
Plenty of resources are available to help counsel women who choose to breastfeed their infants, but the information bears repeating, as nutrient shortfalls are common. “The latest [National Health and Nutrition Examination Survey] data found that 47% of pregnant or breast-feeding women have at least one micronutrient deficiency,” Nichols says. Nutrients that may require supplementation include iron, iodine, folic acid, and vitamin D.2 Nichols recommends that a prenatal vitamin taken during pregnancy be continued postpartum for a minimum of six months or as long as breast-feeding continues. The following nutrients have been singled out because of typically low levels in the diet.
Choline is an important nutrient for women before, during, and after pregnancy. However, most women don’t get enough from their diets. Approximately 90% to 95% of pregnant women consume an inadequate amount of choline.5 That’s even more the case for women who are breast-feeding because choline requirements increase above what’s recommended during pregnancy.
Nevertheless, many over-the-counter multivitamins and mineral supplements, as well as prescription prenatal supplements, lack adequate choline. No Recommended Dietary Allowance (RDA) has been established for choline. Yet, the Food and Nutrition Board, which is responsible for setting RDAs for nutrients, has established an Adequate Intake for women of childbearing age of 425 mg/day; during pregnancy, the suggested intake is 450 mg/day, and when breastfeeding it’s 550 mg/day.6
The main dietary sources of choline in the United States are animal-based products that are particularly rich in choline—such as meat, poultry, fish, dairy products, and eggs. Cruciferous vegetables also are good sources. Despite eating these foods, most people in the United States consume less than the Adequate Intake for choline.7 When counseling a breast-feeding mom about supplementation, be sure to recommend one that contains choline.
DHA and EPA
Studies have reported breastmilk DHA levels in some areas of the United States are among the lowest in the world.8 That’s reason enough to make sure DHA intakes are adequate in breast-feeding women. Fish oils are the most common source of supplemental DHA. One study found that among breast-feeding women four to six weeks postpartum given either placebo, 200 mg, or 400 mg DHA for six weeks along with their usual diets, breastmilk and maternal plasma DHA were significantly greater compared with placebo. DHA supplementation also impacted infants’ plasma levels of fatty acids that are important for brain development.9
While there’s no RDA for DHA or EPA, which is partially converted to DHA in the body, current dietary recommendations for nursing mothers is 250 to 375 mg daily of DHA plus EPA combined.10 If a fishy odor in breastmilk is a concern, one study found that odor isn’t changed by even long-term maternal fish oil consumption.11
Jerlyn Jones, MS, MPA, RDN, LD, CLT, owner of the Lifestyle Dietitian LLC, based in Atlanta, and a spokesperson for the Academy of Nutrition and Dietetics, recommends pregnant and breast-feeding women who are vegan supplement with 100 mg to 200 mg of DHA to meet increased requirements. “Algae-derived DHA is an alternative for vegans,” Jones says. Fish oil up to 3 g daily is Generally Recognized as Safe by the FDA.
The role of vitamin D supplementation postpartum is just beginning to be understood.2 One area of particular interest is vitamin D and postpartum depression (PPD), addressed later in this article.
Breastmilk contains very little of the active form of vitamin D. Maternal supplementation increases levels in both maternal serum and breastmilk. Studies have suggested that large doses of 6,000 IU or higher of vitamin D may be needed to ensure breast-fed infants receive the appropriate amounts of vitamin D through breastmilk. That’s significantly greater than the currently recommended intake of 600 IU per day.2 Before recommending such high doses of vitamin D, it’s best to consult with the patient’s health care provider.
Supplements for Special Circumstances
Because there are no specific, official supplement recommendations for women postpartum, it stands to reason there are no official recommendations for special postpartum circumstances, such as vegetarians and vegans, women who give birth to multiples, or who deliver via C-section. However, some dietitians who counsel pregnant and postpartum women offer advice.
Vegetarians and Vegans
While nutrient needs postpartum are the same for vegetarians and vegans as they are for any other woman postpartum, they do need to be more intentional in their food choices to ensure they’re meeting their nutritional needs. “Some specific nutrients that are often easier to obtain from animal food sources and are important postpartum for vegetarians and vegans are vitamin B12, iron, iodine, choline, and zinc,” Paetow says. If any of those nutrients fall short in the diet, then a supplement that provides them can bring nutrient levels back up to recommended levels. The Academy recommends vitamin B12 supplementation during pregnancy and breast-feeding for mothers who eat vegan or lacto-ovo vegetarian diets.12 However, one study found that concentrations of vitamin B12 in breastmilk were low in vegans (19.2%), vegetarians (18.2%), and nonvegetarians (15.4%) alike.13
For vegetarian moms, getting plenty of plant sources of iron alongside plant foods rich in vitamin C to increase iron absorption also becomes important. If getting enough through diet is difficult or impossible, then a supplement containing both iron and vitamin C should be considered.
C-Sections, Multiples, and Frequent Pregnancies
As with other postpartum circumstances, there are no specific recommendations for women postpartum who have delivered via C-section, who have given birth to multiples, or who have had several pregnancies spaced closely together, but there are some nutrient considerations to take into account. “No evidence-based research on specific vitamin and mineral needs after a C-section exists,” Jones says.
However, blood loss in a delivery by C-section is twice that of an uncomplicated vaginal birth, tissue repair takes a longer period of time following the birth, and there’s a greater risk of infection from the incision.14 Increased blood loss also is a factor when giving birth to multiples. That greater blood loss can translate into higher risk of anemia, so getting enough iron postpartum is especially important for these women and a supplement often is needed. The same holds true for women with multiple sequential pregnancies.15
Postpartum healing also affects nutrient needs. “For the same reasons we recommend focusing on particular micronutrients for postsurgical patients to support wound healing, the intake of micronutrients such as zinc, vitamin A, and vitamin C is important postpartum,” Paetow says. However, she adds that because research on specific nutrient needs during the postpartum period is lacking, she uses clinical judgment when supporting these patients. Individualization is paramount, she says.
Evidence suggests that certain micronutrient deficiencies contribute to PPD development.16 There’s no definitive evidence to show that dietary supplements can alleviate PPD, but a few studies suggest a possible association. Supplementation with omega-3 fatty acids has been studied for reduction of PPD in nursing mothers. A meta-analysis of 35 randomized controlled trials found that women with a diagnosis of severe depression obtained benefit from omega-3 fatty acids, but those with mild depression didn’t.17
Several high-quality studies have suggested that postpartum women with low blood levels of vitamin D are more likely to suffer from depression compared with those with higher blood levels of the vitamin. However, the current state of knowledge isn’t enough to provide a basis for making clinical recommendations.18,19 A better understanding of these mechanisms is important for guiding future research, clinical practice, and health education regarding PPD.
A few supplements are specifically marketed for postpartum women, but Paetow says they’re inconsistent in their nutrient contents. “Some postpartum supplements aren’t that much different than prenatal supplements, but some are.” She suggests looking at the nutrient levels on the Nutrition Facts panel and recommends a supplement that’s suited to the individual’s needs based on their diet and health factors. While there are Dietary Reference Intakes for vitamins and minerals that take breast-feeding into consideration, none specifically take postpartum healing into consideration, making the dietitian’s role that much more important.
— Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas.
1. Optimizing postpartum care. American College of Obstetricians and Gynecologists website. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care. Published May 2018. Accessed August 25, 2020.
2. Beluska-Turkan K, Korczak R, Hartell B, et al. Nutritional gaps and supplementation in the first 1000 days. Nutrients. 2019;11(12):2891.
3. Maternal diet. Centers for Disease Control and Prevention website. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/maternal-diet.html. Updated February 10, 2020. Accessed August 23, 2020.
4. World Health Organization. Iron and folate supplementation. https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/iron_folate_supplementation.pdf?ua=1. Published 2006. Accessed August 25, 2020.
5. Brunst KJ, Wright RO, DiGioia K, et al. Racial/ethnic and sociodemographic factors associated with micronutrient intakes and inadequacies among pregnant women in an urban US population. Public Health Nutr. 2014;17(9):1960-1970.
6. Zeisel SH, da Costa KA. Choline: an essential nutrient for public health. Nutr Rev. 2009;67(11):615-623.
7. Choline: fact sheet for health professionals. National Institutes of Health, Office of Dietary Supplements website. https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/. Updated July 10, 2020. Accessed August 20, 2020.
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10. US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 2015–2020: Eighth Edition. https://health.gov/our-work/food-nutrition/2015-2020-dietary-guidelines/guidelines/. Published January 7, 2016.
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12. Kaiser L, Allen LH, American Dietetic Association. Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc. 2008;108(3):553-561.
13. Pawlak R, Vos P, Shahab-Ferdows S, Hampel D, Allen LH, Perrin MT. Vitamin B-12 content in breast milk of vegan, vegetarian, and nonvegetarian lactating women in the United States. Am J Clin Nutr. 2018;108(3):525-531.
14. A novel technique of uterine cooling during repeated cesarean section for reducing blood loss. ClinicalTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT03793153. Updated April 9, 2019. Accessed August 30, 2020.
15. Ru Y, Pressman EK, Cooper EM, et al. Iron deficiency and anemia are prevalent in women with multiple gestations. Am J Clin Nutr. 2016;104(4):1052-1060.
16. Ellsworth-Bowers ER, Corwin EJ. Nutrition and the psychoneuroimmunology of postpartum depression. Nutr Res Rev. 2012;25(1):180-192.
17. Appleton KM, Rogers PJ, Ness AR. Updated systematic review and meta-analysis of the effects of n-3 long-chain polyunsaturated fatty acids on depressed mood. Am J Clin Nutr. 2010;91(3):757-770.
18. Trujillo J, Vieira MC, Lepsch J, et al. A systematic review of the associations between maternal nutritional biomarkers and depression and/or anxiety during pregnancy and postpartum. J Affect Disord. 2018;232:185-203.
19. Aghajafari F, Letourneau N, Mahinpey N, Cosic N, Giesbrecht G. Vitamin D deficiency and antenatal and postpartum depression: a systematic review. Nutrients. 2018;10(4):478.