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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

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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 the

increased 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

for

baseline 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 the

two 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

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0

.

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C i8 .C 0

(4)

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

1. Sjolin 5, Hofvander Y, Hillervik C. Factors related to early termination of breast-feeding: a retrospective study in Swe-den. Acta Paediatr Scand. 1977;66:505-511

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

1984;106:207-211

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

&Garden Bulletin No. 72 (rev). Washington, DC: US Dept of Agriculture; 1981

13. Cochran WC, Cox GM. Experimental Design. ed 2. New York, NY: John Wiley & Sons, 1957;127-131

14. Weight by height and age for adults 19-74 years, 1971-74.

VitalHealth Stat [11]. 1979;208:1-56

15. Wilson ED, Fisher KH, Fuqua ME. Principles of Nutrition.

New York, NY: John Wiley & Sons; 1975

16. Olsen A. Nursing under conditions of thirst or excessive

ingestion of fluids. Acta Obstet Gynecol Scand. 1940;20:313-343

17. Illingworth RS, Kilpatrick B. Lactation and fluid intake. Lancet. 1953;2:1175-1177

18. Butte NF, Garza C, Smith EO, Nicholas BL. Human milk

intake and growth in exclusively breast-fed infants. J

Pe-diatr. 1984;104:187-195

19. Neville MC, Keller R, Seacat J, et al. Studies in human lactation: Milk volumes in lactating women during the onset of lactation and full lactation. Am J Clin Nutr.

1988;48:1375-1386

20. Lawrence RA. Breast feeding: A Guide for the Medical Profession. St. Louis, MO: The CV Mosby Co; 1980:127-128

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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