Prolonged
Maternal
Fluid Supplementation
in
Breast-Feeding
Lois
B. Dusdieker,
MD; MS; Phyllis
J. Stumbo,
PhD; RD;
Brenda
M. Booth, MA; and Rosemary
N. Wilmoth,
MA
From the Department of Pediatrics and the Clinical Research Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa
ABSTRACT. A randomized, crossover study design was
used to evaluate the effect of prolonged maternal fluid supplementation on the milk supply of breast-feeding women. A total of 19 well-nourished women whose in-fants were solely breast-fed and thriving were enrolled
when their infants were 90 to 120 days of age. Of this group, 15 women consumed at least a 25% increase in fluids above baseline for 7 days. Mean daily milk produc-tion was 767 ± 178 mL for the baseline period and 744 ±
138 mL for the increased fluid period. There was no
significant change in milk production between baseline
and increased fluid periods. No significant linear rela-tionship between the percentage increase in fluid intake
and percentage change in milk production was found.
Pediatrics 1990;86:737-740; breast-feeding, fluid supple-mentation, human milk.
An inadequate milk supply is a common reason given by breast-feeding women for early wean-ing.’ In an attempt to increase their milk produc-tion, women for years have been encouraged to get more rest, to nurse more often,57 and to drink more fluids.8’9
In our earlier study’#{176}in which we evaluated the relationship between maternal fluid intake and sub-sequent milk production, we found that milk pro-duction was not increased if women consumed 25% or more fluids than usual for a 3-day period. We were uncertain, however, whether an appreciable change in milk production could occur this rapidly. The purpose of this second study is to evaluate the effect of increased maternal fluid intake on milk production after a prolonged period of fluid
supple-mentation.
Received for publication Aug 28, 1989; accepted Dec 4, 1989.
Reprint requests to (L.B.D.) Pediatrics-2561 JCP, University of Iowa Hospitals and Clinics, Iowa City IA 52242.
PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the
American Academy of Pediatrics.
METHODS
Breast-feeding woman-infant pairs were
re-cruited from the Pediatric Child Health Clinic,
University of Iowa Hospitals and Clinics. The healthy, well-nourished women were 18 years of age
or older. The healthy infants were 90 to 125 days
of age at enrollment, born appropriate or large for gestational age at 38 to 42 weeks gestation, and
received only breast milk as nourishment. The
proj-ect was approved by the University Committee on
Research Involving Human Subjects.
The participants were weighed and measured by nursing personnel at the initial clinical research
center visit. The research dietitian (P.J.S.)
meas-ured the mother’s triceps skin-fold thickness in the nondominant arm” and instructed the women in diet-recording techniques such as measuring bev-erages in ounces and food portions in cups or
table-spoons.
The women then completed a 3-day diet record
of customary food and beverage intake. The re-search dietitian reviewed the diet record with each participant and hand coded the diet record entries.
Calorie and water contents of the 3-day diets were determined using a computer program written for the project. Calculations of dietary water were made
by multiplying the percentage of water in the food by food weight using published values.’2 Using the initial 3-day diet record as an example of baseline
intake, we calculated a 25% increase in total dietary water (from food and beverage).
During the initial diet-recording period, research personnel delivered an Egnell electric breast pump and Pennsylvania infant scale to each participant’s
home, calibrated the scale in a stationary location,
and then taught the mother how to operate the
738
MATERNAL
FLUID SUPPLEMENTATION
weighing accuracy. Instructions in the use and cleaning of the breast pump, measuring volumes by
syringe, and collecting urine specimens were also given by the research personnel.
In this crossover study, each mother completed both study sections. Participants were randomly
assigned to either study sequence 1 (3 days of baseline fluids followed by 7 days of 25% increased fluids) or study sequence 2 (7 days of 25% increased fluids followed by 3 days of baseline fluids). Ran-domization was performed using tables of random numbers within blocks of 10 to assure even alloca-tion to the sequences throughout the duration of the study. The women were asked to keep daily
intake records of all
food,
beverage, and water sup-plements consumed during the baseline and in-creased fluid sections of both sequences. The 25% fluid supplement was given as water, with half the daily supplement taken midmorning and the re-mainder midafternoon. Additional fluids in excess of the supplement were permitted if the mother desired.For specific gravity determination, mothers were asked to collect a urine specimen before and 1 hour after each water supplement was consumed. The women were instructed to keep their physical
activ-ity consistent throughout the study duration.
Milk production measurement techniques were similar to those described earlier.’0 The women were instructed to weigh the infants before and after each feeding in the same clothing and diapers. Weights were double checked and recorded to the nearest 10 g. After the infant finished nursing, the mother used the electric breast pump until milk stopped spurting from the nipple. The volume of expressed milk was measured in milliliters (1 mL
= 1 g). Women who were separated from their
infants for a feeding were instructed to measure
and record the volume of milk expressed by hand
or breast pump. Women who leaked milk either between or during feedings were asked to wear preweighed, absorbent breast pads that were then
stored in airtight containers in the refrigerator until
reweighed.
Milk production was measured on days 2 and 3 of baseline fluids and days 6 and 7 of increased fluids. For each baseline or increased fluid section 48-hour milk production was calculated as the sum
of the test weights plus the volume of milk ex-pressed after nursing plus the amount of milk leaked into breast pads.
STATISTICAL
ANALYSIS
Paired t tests and analysis of variance procedures
for a crossover design were used to compare total
milk production between baseline and increased
fluid study sections.13 Linear and multiple
regres-sion techniques were used to investigate other in-teractions of milk volume and fluid intake. Our
sample size was large enough for us to detect a 25% difference in milk volume between study sections
with a power of 80%.
RESULTS
A total of 19 healthy woman-infant pairs were
enrolled and completed both study sections. The study mothers were white, married, and well-edu-cated (mean 16.75 years of schooling). The mean
age of the study women was 30.8 years and 5 were
primipara. Maternal measurements for mean height (162.2 ± 5.5 cm), mean weight (62.2 ± 7.0 kg), and mean triceps skinfold thickness (21.6 mm)
were within expected norms.11”4 The 11 baby boys and 8 baby girls were similar in age and growing
well.’5
All 19 women completed detailed diet records, recorded 48-hour test weighings, measured milk
volumes expressed or leaked, and had urine specific
gravities that were lower after taking fluid
supple-ment than before. Four women, however, drank
their calculated water supplements but decreased
their customary dietary fluid intake. Hence, their
overall fluid intake was not 25% above baseline for the entire 7-day period of increased fluids. The 15 compliant women were similar in mean age, height,
weight, triceps skinfold thickness, and education to the initial 19 women enrolled. All noncompliant mothers were multiparae. Results are described for
the compliant mothers only.
The mean daily milk productions were 767 ±
178
mL for the baseline and 744 ± 138 mL for theincreased fluid section (Table). Test weighings
showed that the mean volume per feeding was 125
± 58 mL for baseline and 123.5 ± 58 mL for the increased fluid section. Electric breast pump
expression of milk after nursing averaged only 9 mL for baseline and 13 mL for increased fluids.
Milk leakage into absorbent breast pads occurred
rarely and in insignificant amounts; hence, it was not included in further analysis.
On the average, the women increased their fluid intake by 33.4% (range 26.5% to 40.3%) above their
baselines. The average fluid intake per day from
both food and beverage was 2715 ±
782 mL
forbaseline and 4050 ± 1007 mL for increased fluid
supplementation. Total caloric intake and total fluids from food were not significantly different between study sections.
Total milk production was not significantly
dif-ferent between baseline and increased fluid study
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* Data are given as means ± SD.
20
15
10
5
,
0 0
-6 c.
-10
-15’ 0
0
-20
-0 -25’
-30’
-35,
0
-40 1 V I I I I I I I I I
25 27 25 25 30 31 32 33 34 35 35 37 30 39 40 41 42
%Increase in Fluid Intake
Figure. Relationship between percentage increase in fluid intake and percentage change
in milk production in excess of baseline level.
period (t =
.50,
P = .62). Milk production for thetwo study periods was highly correlated (r =
.83,
P= .001). The effect of study sequence was evaluated
by three-way analysis of variance, controlling for
order. No effect of sequence or order was found. No significant linear relationship was found between
percentage increase in fluid intake and percentage change in milk production in excess of baseline
(Figure). A significant correlation between caloric intake and volume of milk produced was also not found. Parity also did not significantly affect
vol-ume of milk produced.
DISCUSSION
When women who are completely breast-feeding increase their intake of fluids by 25% or more, total milk production does not increase after 3 days’#{176}or
even after 7 days. Observations of Olsen’6 and others,’7 reporting many years ago using the less refined techniques of that time, were supported by
this crossover design study. With our previously
described technique for measurement of milk, we found milk production to be similar in volume to our previously reported work’#{176} and that of
others’8”9 for infants of similar age.
The participating women had extensive dietary supervision. Four of our subjects, however, were
unable to increase their fluids by at least 25%. Although these mothers managed to drink their fluid supplements, their dietary fluid intake de-creased below baseline level. Several women
re-ported that it was hard to drink when they were
not thirsty-especially for a prolonged period such as a week. Olsen’6 earlier reported that some women felt “turgid” and “unwell” while consuming exces-sive fluids. It is unclear whether the mothers felt
pressured or stressed by the requirement to drink when not thirsty or by other study demands. Stress
itself may interfere with hypothalmic function and
subsequently decrease milk production.2#{176} Recom-mendations to markedly increase fluid intake are easy to make, but difficult for certain nursing moth-ers to follow.
TABLE. Daily Dietary Intake and Milk Production*
Study Section
Baseline Fluids Increased Fluids
Total fluid intake (mL) Fluid from food (mL)
Caloric intake (Kcal)
Total milk production (mL)
2715 ± 782
634 ± 192
2316 ± 549
767 ± 178
4050 ± 1007
594 ± 185 2482 ± 692
744 ± 138
C
0
1-)C-)
V
0
.
C -‘-I
a) cdl
C i8 .C 0
740
MATERNAL
FLUID SUPPLEMENTATION
The mothers of thriving breast-fed infants in our
study are a different population than the mothers
of infants who fail to thrive at the breast. We were
unable to show a relationship between maternal
fluid intake and increased breast milk production in our study population. However, we do not know whether breast-feeding mothers whose infants are
growing poorly would respond to increased fluid
intake differently. Such a study should be done with close observation and caution.
ACKNOWLEDGMENTS
This work was supported, in part, by grant RR-59 from the Clinical Research Centers Program, National Insti-tutes of Health.
We thank Egnell, mc, for supplying an Egnell electric
breast pump for use in the study and LaVonne Gebel for
preparation of the manuscript.
REFERENCES
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2. Sjolin S, Hofvander Y, Hillervik C. A prospective study of individual courses of breast-feeding. Acta Paediatr Scand.
1979;68:521-529
3. Verronen P. Breast-feeding: reasons for giving up and
trans-cient lactational crises. Acta Paediatr Scand.
1982;71:447-450
4. Whichelow MJ. Breast feeding in Cambridge, England: fac-tors affecting the mother’s milk supply. J Adv Nurs.
1979;4:253-261
5. Applebaum RM. The modern management of successful breast-feeding. Paediatr Clin North Am. 1970;17:203-225
6. Macy IG, Hunscher HA, Donelson E, Nims B. Human milk
flow.Am J Dis Child. 1930;39:1186-1204
7. Dewey KG, Lonnerdal B. Infant self-regulation of breast milk intake. Acta Paediatr Scand. 1986;75:893-898
8. Filer U. Maternal nutrition in lactation. Clin Perinatol.
1975;2:353-360
9. Nichols BL, Nichols VN. Human milk: nutritional resource. In: Tsang RG, Nichols BL, ed. Nutrition and Child Health: Perspectives for the 1980’s. New York, NY: Alan R. Liss;
1981: 109-146
10. Dusdieker L, Booth B, Stumbo P, Eichenberger J. Effect of supplemental fluids on human milk production. J Pediatr
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11. Frisancho AR. Triceps skin fold and upper arm muscle size norms for assessment of nutritional status. Am J Gun Nutr.
1974;27:1052-1058
12. Adams CF, Richardson M. Nutritive value of foods. Home
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14. Weight by height and age for adults 19-74 years, 1971-74.
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15. Wilson ED, Fisher KH, Fuqua ME. Principles of Nutrition.
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16. Olsen A. Nursing under conditions of thirst or excessive
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SIR WILLIAM
OSLER
ON THE
VALUE
OF OPIUM
IN THE
TREATMENT
OF DIABETES (1917)
In the eighth edition (1917) of his highly-acclaimed textbook of medicine
Osler described the medicinal treatment of diabetes mellitus as follows’:
Opium alone stands the test of experience as a remedy capable of limiting the progress of the disease [diabetes]. Codeia [codeine] is less constipating than morphia. A patient
may begin with half a grain three times a day, which may be gradually increased to 6 or 8 grains in the twenty-four hours. Not much effect is noticed unless the patient is on a rigid diet.
When the sugar is reduced to a minimum, or is absent, the opium should be gradually withdrawn. The patients not only bear well these large doses of the drug, but they stand
its gradual reduction.
REFERENCES
1 Osler W. The Principkes and Practice of Medicine. 8th ed. New York: D. Appleton; 1917:437.
Noted by T.E.C., Jr, MD
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1990;86;737
Pediatrics
Lois B. Dusdieker, Phyllis J. Stumbo, Brenda M. Booth and Rosemary N. Wilmoth
Prolonged Maternal Fluid Supplementation in Breast-Feeding
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Prolonged Maternal Fluid Supplementation in Breast-Feeding
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