1.1 Biochemistry
Exclusive breastfeeding for the first 6 months of life provides all the nutrients and water that an infant needs to grow and develop. After 6 months, other nutritionally adequate and safe foods should be added to the infant's diet, with breastfeeding continuing to 2 years of age or beyond.1
The composition of breastmilk is relatively constant with minimal fluctuations caused by maternal diet, even when the mother's food intake is inadequate (eg famine). 2
Unlike the nutrition received by the fetus through the placenta, the nutrition received by breastfed infants is not dependent on the status of maternal metabolism.
For her own well-being a well-nourished woman should aim to consume an additional 500 kcal per day in the form of nutritious snacks. 3 Additional fluid requirements are met by recommending drinking sufficient water to avoid thirst. Consuming volumes of water in excess to needs will NOT increase breastmilk production. 4 5
a. Protein
Human milk contains approximately 9g/L of protein, decreasing as lactation progresses. 6 This is less than measured protein in cows milk, however it is of higher biological value and, obviously, perfect for a human infant. 7
Whey proteins form the predominant proteins in breastmilk - approximately 60%. Casein forms the remaining 40%. These values are approximate... some texts showing the ratio may be between 80:20 at different stages of lactation to 50:50 (in very late lactation).
The high concentration of whey proteins are digested quickly and easily in the infant's stomach. Breastmilk casein has a mainly nutritive function, providing minerals and essential amino acids to the infant.
Proteins in breastmilk also have other functions such as:
- essential amino acids for growth
- protective factors (eg. immunoglobulins, lactoferrin, etc.)
- carriers for hormones (eg. thyroxine, cortisone-binding proteins)
- carriers for vitamins (eg folate, Vit D, Vit B12 binding proteins)
- enzymatic activity (eg amylase, lipase)
- growth factors (eg insulin-like growth factor, epidermal growth factor)

Did you know...?
The high concentration of whey proteins and the soft, flocculent curds formed by breastmilk casein is the reason why breastfed babies do not get constipated. If a mother is concerned her baby might be constipated it is important to investigate the cause, because this is NOT normal for the (exclusively) breastfed baby.
Cow milk casein (the predominant protein in cow's milk) forms a tough, less digestible curd.

In the Journals
Several observational studies have shown an association between a high protein intake (>15 energy %) early in life and an increased risk of developing obesity and thereby non-communicable diseases (NCDs) later in life.
...
It is also plausible that an important reason for the slower growth in breast-fed infants is the lower content of protein breastmilk, but other qualities of breastmilk could also play a role.
A high intake of protein, especially dairy protein [in infant formula], stimulates the growth factors insulin-like growth factor (IGF-I) and insulin, and it has been suggested that the lower risk of NCDs in breast-fed infants is mediated through a regulation of IGF-I. 8Nutr Metab Cardiovasc Dis. 2012;22(10)

Workbook Activity 1.1
b. Carbohydrates
Lactose (milk sugar) is the principle carbohydrate in human milk. Lactose is the most stable component of mature breastmilk. Lactose is synthesized in the mother's breast and broken down by the enzyme lactase in the baby's small intestine.
The enzyme lactase breaks lactose into glucose and galactose, ready for absorption into the blood stream.
The role of lactose:
- The rapid increase of lactose levels in colostrum at secretory activation (the milk 'coming in', also referred to as lactogenesis II) causes osmotic drawing of water into the breast secretion resulting in copious breastmilk production.
- Provides energy to the body - and particularly to the rapidly growing infant brain.
- Enhances absorption of calcium and iron.
- Galactose is ultimately essential for development of central nervous system.
There have been around 130 different oligosaccharides (short chains of sugar molecules) identified in human milk.9 These important sugars comprise up to 1.2% of mature human milk, compared to only 0.1% of cow's milk. Their role is in protection of the infant from infections.

Food for thought...
At a concentration of 70g/L, human milk has the highest concentration of lactose of all the mammalian milks. Have you ever wondered why? Could it be because the human brain has the MOST growth of all mammal species to accomplish over the next two years and lactose contains elements essential to brain growth?
Consider what effects a lactose-free artificial infant formula could have on the infant fed on it. Discuss this with your colleagues.

Workbook Activity 1.2
Complete Activity 1.2 in your workbook.
c. Milk Lipids (fats)
Properties of milk lipids:
- provide around half of the energy (kilojoules) in breastmilk
- essential for the synthesis and development of retinal and neural tissues
- are a rich source of the essential fatty acids linoleic acid and alpha-linolenic acid and their long-chain derivatives arachidonic acid (AA) and docosahexaenoic acid (DHA). DHA is essential for the developing visual system.
Milk lipids are the most variable constituent of human milk.
This variability is directly related to the amount of milk held in the breast at that time .
Milk removed when the breast is fullest has a low concentration of fat. Fat concentration increases in a linear fashion as more and more milk is removed. 10

© Dr Jacqueline Kent, Biochemistry and Molecular Biology, The University of Western Australia
Illustrated is a series of samples from an expression collected in 1mL fractions. The fat is seen as small clumps of white towards the top of each tube.
The samples are, in order from left to right, a fore-milk sample (hand-expressed), a stimulation sample (the first milk removed by the breast pump), 7 samples collected during the expression, and a final sample hand-expressed after pumping. The initial sample is 5.6% cream (fat) and the final is 18.3% cream (fat).
For this mother this represents a change in degree of breast fullness from 0.55 (about half full) to 0.0 (well-drained).11

Workbook Activity 1.3
Complete Activity 1.3 in your workbook.
Foremilk vs Hindmilk
Many misunderstandings surround the use of these terms. The milk available at the beginning of a breastfeed is sometimes known as foremilk, and hindmilk is often used to describe the milk consumed by the infant at the end of the breastfeed.
The only difference between foremilk and hindmilk is in fat content, with foremilk having a lower fat content than hindmilk at a given breastfeed. You have just learned that the fat content increases in a linear fashion as milk is removed from the breast during that breastfeed, therefore, the change from foremilk to hindmilk is not defined. Use of the terms 'foremilk' and 'hindmilk' may be misrepresentative.
Breastmilk storage capacity
Breastmilk is stored in the alveoli of the breast, and storage capacity of the breast is unique for every woman and every breast. Some mothers may have a large storage capacity, while others may have a very small capacity, and most women have differing capacity in each breast.12,13,14 You cannot accurately judge a woman's breast capacity visually - don't assume that a large breasted woman has a large capacity.
For a mother who has a large storage capacity the milk received by her baby while the breast is at its fullest will be low in fat. After breastfeeding several times the volume in the breast will be reduced and the fat content of subsequent feeds will be much higher. However, for the mother with a small storage capacity, her baby may remove all or most of the breastmilk at most feeds. The fat content of breastmilk at each feed will be similar.

Clinical Tip
Mothers should follow their baby's feeding cues. The mother with the smaller breastmilk storage capacity will find her baby will cue to feed frequently. The mother with the larger storage capacity may find her baby takes larger feeds and requests fewer feedings. Both babies may consume similar amounts of breastmilk over a 24-hour period and both will grow equally as well. Scheduling feeding may work for some babies but cause other babies to be very unhappy and cause failure to thrive.
Cholesterol
The level of cholesterol in breastmilk remains constant (10-20mg/dL) despite dietary manipulation of the mother's cholesterol intake. There is negligible cholesterol in artificial infant formula.
Cholesterol is required to build and maintain cell membranes. Amongst other important tissues it is involved in laying down the myelin sheath which covers the axons of nerve cells in the rapidly growing brain and spinal cord. Multiple sclerosis, a problem of myelinisation, is much more prevalent in countries where artificial infant feeding is common. 15,16
The high level of cholesterol in breastmilk appears to have a 'programming' effect on infants, protecting them from detrimental effects in later life, with adults who were artificially-fed having significantly higher total cholesterol levels and incidence of coronary heart disease. 17 18 19
d. Vitamins
- Vitamin A
- necessary for vision and maintenance of epithelial structures
- adequate stores laid down in the fetal liver during the last trimester
- human milk is an excellent source of vitamin A20
- Vitamin D
- synthesized in the skin from cholesterol on exposure to UVB radiation (sunshine)
- stimulates intestinal absorption and renal reabsorption of calcium and phosphorus
- involved in bone resorption and bone formation
- fetal stores of Vitamin D in infants born to mothers with normal status may be depleted by 2 months of age in the absence of any exposure to sunlight
- breastmilk is a negligible source (20 IU/L) for a recommended need of 400 IU per day 21
- supplementation is recommended for infants who are unlikely to receive adequate Vitamin D from natural sources
- Vitamin E
- mature human milk meets the daily recommended intake
- Vitamin K
- prothrombin, coagulation Factors VII and IX and some plasma proteins are vitamin K-dependent proteins. These are blood clotting factors.
- Vitamin K (phylloquinone) levels in human milk vary considerably depending on maternal diet. Maternal supplementation of 5mg/day increases breastmilk concentration to levels which provide the infant's daily requirement.
- Vitamin K synthesis by bacteria in the large intestine in the first week of life provides insufficient levels for the fully breastfed infant because the predominant gut bacteria (bifidobacteria) does not synthesize Vitamin K.
- Once only intramuscular injection of Vitamin K is recommended for all infants at birth. No other supplementation is required.
- Vitamin B
- Most B vitamins are in appropriate concentrations in breastmilk.
- Where a mother is deficient in B vitamins, supplementing the mother will ensure her breastmilk levels are appropriate.22
Precaution should be taken with Vitamin B6 as mega-doses (ie 600mg/day) have been shown in some studies to reduce maternal prolactin levels, and therefore their breastmilk supply. Usual supplement is 25mg per day . Mothers with a long-term history of oral contraceptive use may be deficient in Vitamin B6. - A strict maternal vegan diet without B12 supplementation has resulted in serious infant morbidity. 23 24 Likewise mothers with gastric bypass surgery are also at risk of Vitamin B12 deficiency. 25 Mothers and infants in this situation should be under the care of a medical and nutrition team.
- Vitamin C
- Vitamin C in breastmilk correlates with maternal intake.26
Levels in breastmilk remain within a normal range, regardless of maternal 'mega' supplementation.
e. Minerals
Concentration of minerals in human milk appears to be quite low, however they have a very high bioavailability and their interrelationship with other nutrients may affect their absorption, metabolism and excretion.
Calcium
Lactating women are often advised to take a calcium supplement or to increase, above normal, their intake of calcium-rich foods. However, in a large study of a group of women in Cambridge UK27 there was no correlation found between calcium intake (ranging from 600 to 2300mg/day) and the amount of calcium in their breastmilk.28
The infant's daily requirement for calcium is adequately met by breastmilk. Bone growth in the infant is unaffected by maternal supplements.
Maternal bone mineral density is not affected adversely by breastfeeding, or enhanced by calcium intake above normal levels. Within 3 months of weaning bone mineral density in breastfeeding women has returned to normal, or is even enhanced.27,29Breastfeeding decreases incidence of osteoporosis in post-menopausal women30 and parity with prolonged total duration of breastfeeding has no detrimental effect on bone mineral density.31
Iron
- levels relatively low but highly bioavailable to infant - five-fold more efficient absorption from human milk than from cows milk32
- breastmilk iron levels are NOT correlated with maternal iron status - levels in breastmilk remain within a normal range even when the mother is anemic33
- the presence of high lactose and Vitamin C levels in breastmilk also aid its absorption
- iron supplements for term infants during the first 6 months of exclusive breastfeeding is unnecessary.34
Complementary foods after 6 months of age should include iron-rich foods. Some infants who continue to be exclusively breastfed for much longer than 6 months may maintain an adequate iron status - biochemical analysis on an individual basis may be indicated.35
Iodine
- required for synthesis of thyroid hormones that are required for brain development during fetal and early postnatal life
- iodine deficiency is a leading cause of brain damage
- breastmilk levels vary widely according to geographic region and maternal intake
- supplementation of women during pregnancy and lactation in iodine-deficient areas will reverse this leading cause of mental impairment32
f. Water
Breastmilk contains a high percentage of water. When babies have unrestricted access to the breast they DO NOT need additional water, even in hot climates. Giving water or other fluids such as teas, will decrease the infant's desire to breastfeed decreasing nutrient intake and breastmilk synthesis, and increasing the infant's risk of infections.
The taste of breastmilk
The flavour (flavor) of breastmilk is affected by the foods in the maternal diet. This daily variation in flavour can help the infant to become used to the tastes of the family foods and ease the transition to these foods when complementary feeding begins.36
Artificial infant formula tastes the same for every feed.
Dietary advice
What should I remember?

- the effect maternal diet has on breastmilk composition.
- proteins: several functions, including immunological protection.
- carbohydrates: the enzyme that breaks down lactose and the two components that are absorbed; the function of those two components.
- lipids: control of levels in breastmilk; functions in infant.
- bioavailability as it relates to vitamins and minerals; know when supplementation is required.
- period of time that breastmilk alone will meet all of the infant's nutritional needs.
Self-test Quiz
Notes
- # World Health Organization (2002) Complementary feeding: Report of the global consultation, and summary of guiding principles for complementary feeding of the breastfed child
- # Neville MC (2001) Anatomy and Physiology of Lactation
- # Picciano MF (2003) Pregnancy and Lactation: Physiological Adjustments, Nutritional Requirements and the Role of Dietary Supplements
- # Dusdieker LB et al. (1990) Prolonged maternal fluid supplementation in breast-feeding.
- # Dusdieker LB et al. (1985) Effect of supplemental fluids on human milk production.
- # Riordan J (2005) Breastfeeding and Human Lactation
- # Hale TW et al. (2007) Textbook of Human Lactation
- # Michaelsen KF et al. (2012) Amount and quality of dietary proteins during the first two years of life in relation to NCD risk in adulthood.
- # McVeagh P et al. (1997) Human milk oligosaccharides: only the breast
- # Daly SE et al. (1993) Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk
- # Kent J (2005) Personal communication
- # Engstrom JL et al. (2007) Comparison of milk output from the right and left breasts during simultaneous pumping in mothers of very low birthweight infants.
- # Ramsay DT et al. (2005) Anatomy of the lactation human breast redefined with ultrasound imaging
- # Cox DB et al. (1997) Studies on Human Lactation: The Development of the Computerized Breast Measurement System
- # Pisacane A et al. (1994) Breastfeeding and multiple sclerosis
- # Conradi S et al. (2013) Breastfeeding is associated with lower risk for multiple sclerosis.
- # Das UN (2003) A perinatal strategy to prevent coronary heart disease
- # Martin RM et al. (2005) Breastfeeding and atherosclerosis: intima-media thickness and plaques at 65-year follow-up of the Boyd Orr cohort
- # Owen CG et al. (2008) Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence.
- # Fujita M et al. (2011) Vitamin A dynamics in breastmilk and liver stores: a life history perspective.
- # Gallo S et al. (2013) Effect of different dosages of oral vitamin D supplementation on vitamin D status in healthy, breastfed infants: a randomized trial.
- # Allen LH (2012) B Vitamins in Breast Milk: Relative Importance of Maternal Status and Intake, and Effects on Infant Status and Function
- # Codazzi D et al. (2005) Coma and respiratory failure in a child with severe vitamin B12 deficiency
- # Allen LH (2008) Causes of vitamin B12 and folate deficiency.
- # Grange DK et al. (1994) Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass
- # Tawfeek HI et al. (2002) Effect of maternal dietary vitamin C intake on the level of vitamin C in breastmilk among nursing mothers in Baghdad, Iraq.
- # Prentice A (2000) Calcium in pregnancy and lactation
- # Kent JC et al. (2009) Why calcium in breastmilk is independent of maternal dietary calcium and vitamin D.
- # Kovacs CS (2005) Calcium and bone metabolism during pregnancy and lactation
- # Schnatz PF et al. (2010) Effects of age at first pregnancy and breast-feeding on the development of postmenopausal osteoporosis.
- # Lenora J et al. (2009) Effects of multiparity and prolonged breast-feeding on maternal bone mineral density: a community-based cross-sectional study.
- # Picciano MF (2001) Nutrient Composition of Human Milk
- # Shashiraj et al. (2006) Mother\'s iron status, breastmilk iron and lactoferrin--are they related?
- # Yang Z et al. (2009) Prevalence and predictors of iron deficiency in fully breastfed infants at 6 mo of age: comparison of data from 6 studies.
- # Griffin IJ (2001) Iron and Breastfeeding
- # Beauchamp GK et al. (2009) Early flavor learning and its impact on later feeding behavior.