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Lactation, conception, and the nutrition of the nursing mother and child
TROPICAL
PEDIATRICS
DerrickB. Jelliffe, Editor
Lactation, conception, and the nutrttwn of the nursing mother and cl 'Id Derrick B. Jelliffe and E. F. Patrice Jelliffe, Kingston, ]arnaica
R E A L I S T I C and practical m a and child health program for technically underdeveloped areas must take into account the very close degree of interdependence between mother and offspring, 1 best emphasized in the hypothesis that biologically the young human organism has three interrelated stages--the intrauterine fetus, the exterogestate fetus (six to nine months), 12 and the "transitional. ''3 A N Y ternal
PUBLIC HEALTH SIGNIFICANCE OF H U M A N M I L K
For the poorly sanitated, impoverished majority of the world's people, breast-feeding is imperative in infant feeding, not only for economic and hygienic reasons, but also as a protection against diarrheal disease in early childhood ("weanling diarrhea")4 and other infections2 Additionally, and underappreciated by nutrieionists, health workers, and economic planners, is the fact that human milk is a major protein food resource, n' 7 In fact, loss of ability to breast-feed in present-day Asia would need to be compensated for by an estimated additional herd of approximately 114 million cattle, or an increase of 40 per cent of the cow's milk production in this populous area2
From the Caribbean Food and Nutrition Institute. Reprint address: School of Public Health, University o[ CalilorMa , Los Angeles, Calit. 90024.
Any realistic maternal and child health program for underdeveloped regions must be based on the interrelationships of lactation, conception, and the nutrition (and general health) of the mother, fetus, and infant. In fact, breast-feeding, family planning, and maternal nutrition are of prime importance in any practical maternal and child health program2 There is considerable published information on these matters, which seems timely to review? ~ 11 In recent decades, the decline in lactation which began in the Western world has spread to less developed parts of the world, initially involving the elite and subsequently some part of the general population in urban and peri-urban regions. 12, 13 The factors responsible for this decline vary in different parts of the world, but include lack of knowledge by health personnel of the psychophysiology of lactation, 14 ill-considered and ill-informed regimens in maternity units, exposure to unethical advertising of hygienically and economically inappropriately processed cow's milk preparations, real or perceived changes in the role of urbanized women (including working outside the home), and a search for apparent moderness and status? 5 There is a great need for a multinational study of the "epidemiology of lactation failure." There is increasing evidence that there is a rising incidence of marasmus and diarrhea in urban and peri-urban areas directly related to this decline in breast-feeding? n-18 Vol. 81, No. 4, pp. 829-833
8 3 0 ]elliffe and ]elliffe
Family planning needs consideration as a component in the national development policy of all countries. Population size is a universal denominator in relation to social services, such as schools, health facilities, waste disposal, and the availability of food. Limitation of family size and adequate spacing between children is also necessary for both economic reasons and the health and nutrition of mothers and offspring. 19 Lactation as a contraceptive. There has been a traditional belief that breast-feeding has a contraceptive effect and delays the onset of the next pregnancy. In some areas, such as parts of West Africa, this was made much more effective by culturally defined periods of abstinence from sexual intercourse after childbirth, often lasting as long as the child was being breast-fed. 2~ 21 In recent years, evidence has accumulated from studies of historical demography in Europe 22 a n d f r o m field investigators in many parts of the world, which substantiates this folk experience and indicates that lactation does, indeed, h a v e a contraceptive effect, presumably because prolactin and other hormones of the lactogenic complex, 28 secreted by the anterior pituitary as a response to sucking the breast, inhibit ovulation. Ovulation and menstruation are delayed for at least ten weeks ~4, ~5 and even up to 26 months, 26 provided breast-feeding is complete, successful, and unrestricted, as usually happens when babies take the breast soon after delivery, and thereafter a t short intervals. The effect is greatly reduced if breast-feeding is partial and supplemented early with other feeds of cow's milk formula Or semisolids, thereby reducing sucking stimulus and the prolactin secretion. 2r, 2s Delay in the onset of menstruation has another beneficial effect on maternal nutrition, permitting some replenishment of iron stores; the saving of iron can be considerable. Up to 40 per cent of the reproductive lives of Indian women from 12 to 40 years of age can be in an anovulatory phase 29 b e c a u s e of either pregnancy or lactation. Evidence concerning the suppression of ovulation and prolongation of postpartum
The
]ournat of Pediatrics October 1972
amenorrhea resulting from lactation is available from body temperature studies and endometrial biopsies 24, 25, 29-38 and from field observations in various developing countries?4, 85 E1-Minawi and Foda,26 in Egypt, reported postpartum lactation amenorrhea, with associated endometrial changes, lasting up to 26 months. In the Philippines, a study in this Catholic country demonstrated that a 24 to 35 month birth-spacing interval was achieved in 51.9 per cent of mothers who breast-fed their infants for 7 to 12 months, as opposed to only 30 per cent of mothers whose infants were artificially fed? 6 Also, in Rwanda in Central Africa prolonged lactation produced amenorrhea in 50 per cent of women for over one year and was also responsible for an over-all delay in pregnancy of 15 months, as compared with a group of women whose babies died at birth and hence were not protected from conception by prolonged lactation. It may be noted that among this community sexual intercourse was culturally permitted from about eight days after deliveryW The numerical extent of this protective effect has been c o m p u t e d in areas of high fertility and of unrestricted and prolonged lactation; it has been estimated tO be responsible for a reduction of as much as 20 per cent of expected births, as Maternal malnutrition and lactation. Considerable information has been gathered on the interrelationships of poor maternal nutrition and lactation in developing countries. In summary, the protein content of human milk is often of a low normal concentration, with vitamin levels (e.g., B~, A) and fatty acid content depending on the mother's diet. ~ Lactation by itself (together with fetal stores and sunlight) is usually adequate to sustain growth and nutrition in the infant for four to six months, 39 but at the cumulative expense of maternal stores. T h e volume of breast milk secreted subsequently comprises a small, declining, but still important, traditional protein supplement to the transitional, weaning diet from six months to two years or more. *~ T h e basic need in this regard is
Volume 81 Number 4
Lactation, conception, nutrition, and breast-feeding
to ensure an actequate diet of economical, locally available foods ("multimixes") 41 for women during pregnancy and lactation in order to avoid cumulative "maternal depletion," either generaP 2 or specific, such as folate deficiency43 with succeeding reproductive cycles. In severe maternal malnutrition, the protein content and volume of breast milk appear to be affected, and in prolonged famine lactation ceases. 4~ Maternal malnutrition and conception. Poorly nourished women are often highly fertile, although when subnutrition becomes extreme, as in famines, amenorrhea and decline in fertility will then ensue. 44 In some instances reduced fertility during prolonged lactation may perhaps be partly due to the mother's inadequate nutritional status with the added prolactin effect of continued breast-feeding. 45 Effect of oral contraceptives on maternal nutrition. Oral contraceptives may interact with some essential dietary nutrients. Increased iron absorption may occur, 45 and there may be higher than usual needs for folic acid, vitamin B12, pyridoxine, and tryptophan, 46-49 especially in communities where such deficiencies axe common. 59 The possibility of "fortifying" some contraceptives with appropriate nutrients needs consideration. Evidence suggests that the earlier ovulation-suppressing contraceptive compounds given by mouth--that is, relatively "largedose" mixed tablets, containing both estrogens and progestagens frequently had a deleterious effect on the production of human milk, especially if introduced soon after delivery, and often made it impossible to continue breast-feeding. 5~ However, more recent experience in East Africa,~, 64 Australia, and the United States, 55 with combined oral contraceptive pills with a low estrogen content, usually produced no ill effect on lactation. Recent contraceptive experience has been with progestagen compounds (progestins) alone, which appear to act by inhibiting sperm penetration into the cervical mucosa,
831
and do not affect ovulation. 56 These have been used orally in Egypt and in East and Central Africa as, for example, chlormadinone. Also noteworthy is the successful use of repository intramuscular progestagen (Depo-Provera) in Uganda by Saxton and Saxton, 57 and in Egypt by Karim and associates. ~s In all of these studies, progestagens used alone did not interfere with milk secretion and may even increase the flow. 5~, 68 Current information also suggests that progestagens have, at most, only a slight effect on the major nutrients of breast milk. 59 However, excretion occurs in the human milk 6~ and, although no evidence of toxicity to the neonate was found in a small study by Miller and I-Iughes, 51 further investigation is needed. Only one case of possibly associated feminization has been described in breast-fed boy.62 SUMMARY
Successful unsupplemented lactation has a definite contraceptive effect lasting for months, which is less effective if early supplementary feeds are given. This contraceptive effect declines with time, and ultimately menstruation, ovulation, and conception are resumed during prolonged breast-feeding. 71 The decline in breast-feeding in newly urbanized families in the shanty towns and slum areas 6~ does not only have direct nutritional ill consequence~ for young children, with an increase in the "diarrhea-marasmus syndrome," but also has an anticontraceptive potential of public health proportions. The importance of breast-feeding needs consideration as one mode of child spacing, especially by religious groups concerned with natural methods. With regard to hormonal contraceptives, the low-dose progestagen drugs, both those given by mouth and by intramuscular injection, do not appear to have major ill effects as far as lactation is concerned, and may even increase the yield. However, further investigation is needed into the effect of various types and doses of contraceptives on the composition and yield of milk in various nutritional circumstances, into possible el-
832
Jelliffe and ]elliffe
fects on the nursing baby, a n d into nutritional consequences in the w o m e n concerned, especially folic acid deficiency. W h a t seems to be needed in less developed regions is initial u n s u p p l e m e n t e d breast-feeding of the i n f a n t for six to eight weeks after birth, followed by a m u t u a l reinforcement of the proved contraceptive effects of lactation and mechanical ( i n t r a u t e r i n e contraceptive devices ~) or h o r m o n a l contraceptives--preferably long-lasting, " o n e - a t t e n d a n c e " methods, such as i n t r a m u s c u l a r Depo-Provera, given initially at the postnatal clinic. Optimally, a h o r m o n a l c o m p o u n d is needed which is not only a contraceptive b u t also has n o nutritional ill consequences for the mother and enhances lactation. Research into these i m p o r t a n t interactions a n d interdependences between m o t h e r a n d i n f a n t should be a priority in world nutrition; there are indications that the efforts needed are being given increased emphasis?0, 11
The lournat of Pediatrics October 1972
10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
20. Thanks are due to Drs. V. Bailey, J. Chopra, R. L. Jackson, D. M. Potts, F. Rosa, S. Sayre, and A. Thomson for advice.
21. 22.
~Intrauterlne devicesmay enhance lactation as a result of soeretion of oxytocln~5or prostaglandlns.6e
23.
REFERENCES
1. World Health Organization: Organization and administration of maternal and child health services, Technical Report Series, No. 428, 1969. 2. Bostock, J.: Evolutional approaches to infant care, Lancet 1: 1033, 1962. 3. Jelliffe, D. B.: The pre-school child as a biocultural transitional, J. Trop. Pedlatr. 14: 217, 1968. 4. Gordon, J. E., Chitkara, L. D., and Wyon, T. B.: Weanling diarrhea, Am. J. Med. Scl. 245: 345, 1963. 5, Jelliffe, D. B., and Jelliffe, E. F. P. (editors): The uniqueness of human milk, Amer. J. Clln. Nutr. 24: 968, 1971. 6. Jelliffe, D. B.: Breast milk and the world protein gap, Clin. Pediatr. 7: 96, 1968. 7. Berg, A.: Nutrition and nations. In press. 8. Jelliffe, D. B., and Jelliffe, E. F. P.: Human milk as an ecological force. Proceedings of First Asian Nutrition Congress. In press. 9. Williams, C. D., and Jelliffe, D. B.: Mother.
24. 25. 26. 27. 28. 29. 30. 31.
and child health delivering the services, London, 1972, Oxford University Press. Chopra, J.: Effect of steroid contraceptives on lactation. In preparation. Latham, M. C.: The effects of lactation on human fertility, National Academy of Sciences. In press. Wong Hock Boon, Paramathypathy, K., and Thas Ngiap Boo: J. Singapore Paediatr. Soc. 5: 89, 1963. Welbourn, H. F.: Bottle-feeding: A disease of civilization, J. Trop. Pediatr. 3: 157, 1958. Jelliffe, D. B., and Jelliffe, E. F. P.: I-Iow breast feeding really works, J. Trop. Pedlatr. 17: 62, 1971. Jelliffe, D. B.: Culture, social change and infant feeding, Am. J. Clin. Nutr. 10: 19, 1962. McLaren, D. S.: Trends in tropical child health. The rise of marasmus, J. Trop. Pediatr. 12: 84, 1966. Jelliffe, D. B.: Commereiogenic malnutrition? Time for a dialogue, Food Technol. 25: 55, 1971. Sadre, N., Emami, E., and Donoso, G.: The changing pattern of malnutrition, Ecology Food Nutr. l: 55, 1972. International Planned Parenthood Federation Working Paper No. 5: The relationship between family size and maternal and child health, London, 1970. Niehoff, A., and Meister, N.: Cultural characteristics of breast feeding: A survey, J. Trop. Pediatr. In press. Martin, W. J., Morley, D., and Woodland, M.: Intervals between births in a Nigerian Village, J. Trop. Pediatr. 10: 83, 1964. Tietze, C.: The effect of breast feeding on the rate of conception, Proc. Int. Population Congress, 1971. Forsyth, I.: The role of primate prolactins and placental lactogens in lactogenesis, in Lactogenesis: The initiation of milk secretion parturition, Philadelphia, 1969, University of Pennsylvania Press, p. 195. Cronin, T. J.: Influence of lactation upon ovulation, Lancet 2: 422, 1968. Gioisa, A. R.: Incidence of pregnancy during lactation {n 500 cases, Am. J. Obstet. Gyneeel. 70: 162, 1955. E1-Minawi, M. F., and Foda, M. S.: Postpartum lactation amenorrhea, Am. J. Obstet. Gyneeol. 111: 19, 1970. McKeown, T., and Gibson, J. R.: A note on menstruation and conception during lactation, J. Obstet. Gyneeol. Br. Emp. 61: 824, 1954. Sharman, A.: Ovulation after pregnancy, Fertil. Steril. 2: 371, 1951. Salber, E. J., Feinleib, M., and Macmahan, B.: The duration of postpartum amenorrhea, Am. J. Epidemiol. 82: 347, 1966. Udesky, I. C.: Ovulation in lactating women, Am. J. Obstet. Gynecol. 59: 843, 1950. Lyon, R. A.,~ and Stamm, M. J.: The onset of ovulation during the puerperlum,, Calif. Med. 65: 99, 1946.
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Lactation, conception, nutrition, and
32. Topkins, P.: Histologic appearance of the dometrium during lactation amenorrhea and its relationship to ovarian function, Am. J. Obstet. Gynecol. 45: 48, 1943. 33. Eastman, N.: The effect of the interval between births on maternal and fetal outlook, Am. J. Obstet. Gynecol. 47: 445, 1944. 34. Matthews, D. S.: The ethnological and medical significance of breast feeding, with special reference to the Yorubas of Nigeria, J. Trop. Pediatr. 1: 9, 1955. 35. Baxi, P. C.: A natural history of childbearing in the hospital class of women in Bombay, J. Obstet. Gynecol. 8: 26, 1957. 36. Del Mundo, F., and Adiao, A.: Lactation and child spacing as observed among 2,102 rural Filipino mothers, Phillip. J. Pediatr. 19: 128, 1970. 37. Bont6, M., and Van Balen, H. J.: Prolonged lactation and family spacing in Rwanda, J. Biosoc. Sci. 1: 97, 1969. 38. Jain, A. K., Hsu, T. C., Freedman, R., and Chang, M. C.: Demographic aspects of lactation and post-partum amenorrhea, Demography 7: 255, 1970. 39. Jackson, R. L., Westerfeld, R., Chopra, M. A., Kimball, R. A., and Lewis, R. B.: Growth of "well-born" American infants fed human and cow's milk, Pediatrics 33: 642, 1964. 40. Oomen, H. A. P. C., and Malcolm, S. H.: Nutrition and the Papuan Child, South Pacific Commission Technical Paper No. 11, 1958. 41. Jelliffe, E. F. P.: Weaning multimlxes for the Caribbean, J. Trop. Pediatr. 17: 135, 1971. 42. Jelliffe, D. B., and Maddocks, I.: Ecologic notes on malnutrition in the New Guinea highlands, Clin. Pediatr. 3: 432, 1964. 43. Metz, J.: Folate deficiency conditioned by lactation, Am. J. Clin. Nutr. 23: 843, 1970. 44. Jelliffe, D. B., and Jelliffe, E. F. P.: The effects of famine on the family and on society, in Nutrition in national disasters, Swedish Nutrition Foundation Symposium, Uppsala, 1971, Almqvist & Wiksells, p. 54. 45. Malkani, P. K., and Mirchandani, J. J.: Menstruation during lactation, J. Obstet. Gynecol. Ind. 11: 11, 1960. 46. Hodges, R. E.: Nutriti6n and the pill, J. Am. Diet. Assoc. 59: 212, 1971. 47. Editorial: The pill and folate metabolism, Br. Med. J. 11: 686, 1971. 48. Rose, D. F., and Braidman, I. P.: Excretion of tryptophan metaholltes as affected by pregnancy, contraceptive steroids and steroid hormones, Am. J. Clin. Nutr. 94: 673, 1971. 49. Luhby, A. L., Brin, M., Gordon, M., Davis, P., Murphy, M., and Spiegel, H.: Vitamin Be metabolism in users of oral contraceptives, Am. J. Clin. Nutr. 24: 684, 1971. 49a. Iyengan, L.: Folio acid requirements of Indian pregnant women, Am. J. Clln. Nutr. 3: 13, 1971.
breast-feeding 83
3
50. Kora, S. J.: Effect of oral contraceptives on lactation, Fertil. Steril. 20: 419, 1968. 51. Rice-Wray, E.: Oral contraception in Laun America, in Proc. Seventh International Planned Parenthood Federation Conference, Singapore, 1964, p. 367. 52. Kamal, I., Hefnani, F., Choneim, M., Talaat, M., Younis, N., Tagui, A., and Abdalla, M.: Clinical biochemical and experimental studies on lactation, Am. J. Obstet. Gynecol. 105: 324, 1969. 53. Hayden, R. J.: Effect of oral contraceptives on lactation, J. Trop. Pediatr. 2: 59, 19e6. 54. Saxton, G.: A review of research related to family planning in Africa, presented at Ford Foundation Workshop on Need Family Planning in East Africa, Nairobi, Kenya, July, 1970. 55. Jelliffe, D. B., and Jelliffe, E. F. P.: The effect of oral contraceptives on lactation in highly motivated women. In preparation. 56. Lead article: Progestagen--only contraception, Lancet 1: 25, 1971. 57. Saxton, G. A., and Saxton, A. K.: Contraception by jet injection, presented at the Association of Physicians of East Africa and Nairobi, Kenya, June, 1970. 58. Karim, M., Ammar, R., E1 Mahgoub, E1 Ganzoury, F., and Abdou, I.: Injected progestagen and lactation, Br. Med. J. 1: 200, 1971. 59. Abdal Kaden, M. M., Abdal Hay, A., E1Safouri, S., Abdal Aziz, M. Kamal, I., Hefnawi, F., Chonein, M., Talaat, M., Younis, N., Tagui, A., and Abdalla, M., III: Biochemical changes induced in human milk by gestagens, Am. J. Obstet. Gynecol. 105: 978, 1969. 60. Lausas, K. R., Malkani, P. K., Bhatnagar, S., and Lausas, V.: Radioactivity in the breast milk of lactating women after oral administration of 3H-norethynodrel, Am. J. Obstet. Gynecol. 98: 411, 1967. 61. Miller, G. H., and Hughes, L. R.: Lactation and genital involution effects of a new lowdose oral contraceptive on breast feeding and their infants, Obstet. Gynecol. 35: 44, 1970. 62. Curtis, E. M.: Oral contraceptive feminization of a normal male infant, Obstet. Gynecol. 23: 395, 1964. 63. Guttmacher, A.: Factors affecting normal expectance of conception, J. A. M. A. 16: 855, 1956. 64. Jelliffe, D. B., and Jelliffe, E. F. P.: The urban avalanche and child nutrition, J. Am. Diet. Assoc. 57: 111, 1970. 65. Gold, E. M.: Report of current studies of maternal nutrition status in the U.S.A., in Maternal nutrition and family planning in the Americas, Pan American Health Organization Scientific Publication No. 204, Washington, D. C., t970. 66. Chaudhuri, C. : Intrauterine device : Possible role of prostaglandins, Lancet 2: 480, 1971.
PEDIATRICS
DerrickB. Jelliffe, Editor
Lactation, conception, and the nutrttwn of the nursing mother and cl 'Id Derrick B. Jelliffe and E. F. Patrice Jelliffe, Kingston, ]arnaica
R E A L I S T I C and practical m a and child health program for technically underdeveloped areas must take into account the very close degree of interdependence between mother and offspring, 1 best emphasized in the hypothesis that biologically the young human organism has three interrelated stages--the intrauterine fetus, the exterogestate fetus (six to nine months), 12 and the "transitional. ''3 A N Y ternal
PUBLIC HEALTH SIGNIFICANCE OF H U M A N M I L K
For the poorly sanitated, impoverished majority of the world's people, breast-feeding is imperative in infant feeding, not only for economic and hygienic reasons, but also as a protection against diarrheal disease in early childhood ("weanling diarrhea")4 and other infections2 Additionally, and underappreciated by nutrieionists, health workers, and economic planners, is the fact that human milk is a major protein food resource, n' 7 In fact, loss of ability to breast-feed in present-day Asia would need to be compensated for by an estimated additional herd of approximately 114 million cattle, or an increase of 40 per cent of the cow's milk production in this populous area2
From the Caribbean Food and Nutrition Institute. Reprint address: School of Public Health, University o[ CalilorMa , Los Angeles, Calit. 90024.
Any realistic maternal and child health program for underdeveloped regions must be based on the interrelationships of lactation, conception, and the nutrition (and general health) of the mother, fetus, and infant. In fact, breast-feeding, family planning, and maternal nutrition are of prime importance in any practical maternal and child health program2 There is considerable published information on these matters, which seems timely to review? ~ 11 In recent decades, the decline in lactation which began in the Western world has spread to less developed parts of the world, initially involving the elite and subsequently some part of the general population in urban and peri-urban regions. 12, 13 The factors responsible for this decline vary in different parts of the world, but include lack of knowledge by health personnel of the psychophysiology of lactation, 14 ill-considered and ill-informed regimens in maternity units, exposure to unethical advertising of hygienically and economically inappropriately processed cow's milk preparations, real or perceived changes in the role of urbanized women (including working outside the home), and a search for apparent moderness and status? 5 There is a great need for a multinational study of the "epidemiology of lactation failure." There is increasing evidence that there is a rising incidence of marasmus and diarrhea in urban and peri-urban areas directly related to this decline in breast-feeding? n-18 Vol. 81, No. 4, pp. 829-833
8 3 0 ]elliffe and ]elliffe
Family planning needs consideration as a component in the national development policy of all countries. Population size is a universal denominator in relation to social services, such as schools, health facilities, waste disposal, and the availability of food. Limitation of family size and adequate spacing between children is also necessary for both economic reasons and the health and nutrition of mothers and offspring. 19 Lactation as a contraceptive. There has been a traditional belief that breast-feeding has a contraceptive effect and delays the onset of the next pregnancy. In some areas, such as parts of West Africa, this was made much more effective by culturally defined periods of abstinence from sexual intercourse after childbirth, often lasting as long as the child was being breast-fed. 2~ 21 In recent years, evidence has accumulated from studies of historical demography in Europe 22 a n d f r o m field investigators in many parts of the world, which substantiates this folk experience and indicates that lactation does, indeed, h a v e a contraceptive effect, presumably because prolactin and other hormones of the lactogenic complex, 28 secreted by the anterior pituitary as a response to sucking the breast, inhibit ovulation. Ovulation and menstruation are delayed for at least ten weeks ~4, ~5 and even up to 26 months, 26 provided breast-feeding is complete, successful, and unrestricted, as usually happens when babies take the breast soon after delivery, and thereafter a t short intervals. The effect is greatly reduced if breast-feeding is partial and supplemented early with other feeds of cow's milk formula Or semisolids, thereby reducing sucking stimulus and the prolactin secretion. 2r, 2s Delay in the onset of menstruation has another beneficial effect on maternal nutrition, permitting some replenishment of iron stores; the saving of iron can be considerable. Up to 40 per cent of the reproductive lives of Indian women from 12 to 40 years of age can be in an anovulatory phase 29 b e c a u s e of either pregnancy or lactation. Evidence concerning the suppression of ovulation and prolongation of postpartum
The
]ournat of Pediatrics October 1972
amenorrhea resulting from lactation is available from body temperature studies and endometrial biopsies 24, 25, 29-38 and from field observations in various developing countries?4, 85 E1-Minawi and Foda,26 in Egypt, reported postpartum lactation amenorrhea, with associated endometrial changes, lasting up to 26 months. In the Philippines, a study in this Catholic country demonstrated that a 24 to 35 month birth-spacing interval was achieved in 51.9 per cent of mothers who breast-fed their infants for 7 to 12 months, as opposed to only 30 per cent of mothers whose infants were artificially fed? 6 Also, in Rwanda in Central Africa prolonged lactation produced amenorrhea in 50 per cent of women for over one year and was also responsible for an over-all delay in pregnancy of 15 months, as compared with a group of women whose babies died at birth and hence were not protected from conception by prolonged lactation. It may be noted that among this community sexual intercourse was culturally permitted from about eight days after deliveryW The numerical extent of this protective effect has been c o m p u t e d in areas of high fertility and of unrestricted and prolonged lactation; it has been estimated tO be responsible for a reduction of as much as 20 per cent of expected births, as Maternal malnutrition and lactation. Considerable information has been gathered on the interrelationships of poor maternal nutrition and lactation in developing countries. In summary, the protein content of human milk is often of a low normal concentration, with vitamin levels (e.g., B~, A) and fatty acid content depending on the mother's diet. ~ Lactation by itself (together with fetal stores and sunlight) is usually adequate to sustain growth and nutrition in the infant for four to six months, 39 but at the cumulative expense of maternal stores. T h e volume of breast milk secreted subsequently comprises a small, declining, but still important, traditional protein supplement to the transitional, weaning diet from six months to two years or more. *~ T h e basic need in this regard is
Volume 81 Number 4
Lactation, conception, nutrition, and breast-feeding
to ensure an actequate diet of economical, locally available foods ("multimixes") 41 for women during pregnancy and lactation in order to avoid cumulative "maternal depletion," either generaP 2 or specific, such as folate deficiency43 with succeeding reproductive cycles. In severe maternal malnutrition, the protein content and volume of breast milk appear to be affected, and in prolonged famine lactation ceases. 4~ Maternal malnutrition and conception. Poorly nourished women are often highly fertile, although when subnutrition becomes extreme, as in famines, amenorrhea and decline in fertility will then ensue. 44 In some instances reduced fertility during prolonged lactation may perhaps be partly due to the mother's inadequate nutritional status with the added prolactin effect of continued breast-feeding. 45 Effect of oral contraceptives on maternal nutrition. Oral contraceptives may interact with some essential dietary nutrients. Increased iron absorption may occur, 45 and there may be higher than usual needs for folic acid, vitamin B12, pyridoxine, and tryptophan, 46-49 especially in communities where such deficiencies axe common. 59 The possibility of "fortifying" some contraceptives with appropriate nutrients needs consideration. Evidence suggests that the earlier ovulation-suppressing contraceptive compounds given by mouth--that is, relatively "largedose" mixed tablets, containing both estrogens and progestagens frequently had a deleterious effect on the production of human milk, especially if introduced soon after delivery, and often made it impossible to continue breast-feeding. 5~ However, more recent experience in East Africa,~, 64 Australia, and the United States, 55 with combined oral contraceptive pills with a low estrogen content, usually produced no ill effect on lactation. Recent contraceptive experience has been with progestagen compounds (progestins) alone, which appear to act by inhibiting sperm penetration into the cervical mucosa,
831
and do not affect ovulation. 56 These have been used orally in Egypt and in East and Central Africa as, for example, chlormadinone. Also noteworthy is the successful use of repository intramuscular progestagen (Depo-Provera) in Uganda by Saxton and Saxton, 57 and in Egypt by Karim and associates. ~s In all of these studies, progestagens used alone did not interfere with milk secretion and may even increase the flow. 5~, 68 Current information also suggests that progestagens have, at most, only a slight effect on the major nutrients of breast milk. 59 However, excretion occurs in the human milk 6~ and, although no evidence of toxicity to the neonate was found in a small study by Miller and I-Iughes, 51 further investigation is needed. Only one case of possibly associated feminization has been described in breast-fed boy.62 SUMMARY
Successful unsupplemented lactation has a definite contraceptive effect lasting for months, which is less effective if early supplementary feeds are given. This contraceptive effect declines with time, and ultimately menstruation, ovulation, and conception are resumed during prolonged breast-feeding. 71 The decline in breast-feeding in newly urbanized families in the shanty towns and slum areas 6~ does not only have direct nutritional ill consequence~ for young children, with an increase in the "diarrhea-marasmus syndrome," but also has an anticontraceptive potential of public health proportions. The importance of breast-feeding needs consideration as one mode of child spacing, especially by religious groups concerned with natural methods. With regard to hormonal contraceptives, the low-dose progestagen drugs, both those given by mouth and by intramuscular injection, do not appear to have major ill effects as far as lactation is concerned, and may even increase the yield. However, further investigation is needed into the effect of various types and doses of contraceptives on the composition and yield of milk in various nutritional circumstances, into possible el-
832
Jelliffe and ]elliffe
fects on the nursing baby, a n d into nutritional consequences in the w o m e n concerned, especially folic acid deficiency. W h a t seems to be needed in less developed regions is initial u n s u p p l e m e n t e d breast-feeding of the i n f a n t for six to eight weeks after birth, followed by a m u t u a l reinforcement of the proved contraceptive effects of lactation and mechanical ( i n t r a u t e r i n e contraceptive devices ~) or h o r m o n a l contraceptives--preferably long-lasting, " o n e - a t t e n d a n c e " methods, such as i n t r a m u s c u l a r Depo-Provera, given initially at the postnatal clinic. Optimally, a h o r m o n a l c o m p o u n d is needed which is not only a contraceptive b u t also has n o nutritional ill consequences for the mother and enhances lactation. Research into these i m p o r t a n t interactions a n d interdependences between m o t h e r a n d i n f a n t should be a priority in world nutrition; there are indications that the efforts needed are being given increased emphasis?0, 11
The lournat of Pediatrics October 1972
10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
20. Thanks are due to Drs. V. Bailey, J. Chopra, R. L. Jackson, D. M. Potts, F. Rosa, S. Sayre, and A. Thomson for advice.
21. 22.
~Intrauterlne devicesmay enhance lactation as a result of soeretion of oxytocln~5or prostaglandlns.6e
23.
REFERENCES
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and child health delivering the services, London, 1972, Oxford University Press. Chopra, J.: Effect of steroid contraceptives on lactation. In preparation. Latham, M. C.: The effects of lactation on human fertility, National Academy of Sciences. In press. Wong Hock Boon, Paramathypathy, K., and Thas Ngiap Boo: J. Singapore Paediatr. Soc. 5: 89, 1963. Welbourn, H. F.: Bottle-feeding: A disease of civilization, J. Trop. Pediatr. 3: 157, 1958. Jelliffe, D. B., and Jelliffe, E. F. P.: I-Iow breast feeding really works, J. Trop. Pedlatr. 17: 62, 1971. Jelliffe, D. B.: Culture, social change and infant feeding, Am. J. Clin. Nutr. 10: 19, 1962. McLaren, D. S.: Trends in tropical child health. The rise of marasmus, J. Trop. Pediatr. 12: 84, 1966. Jelliffe, D. B.: Commereiogenic malnutrition? Time for a dialogue, Food Technol. 25: 55, 1971. Sadre, N., Emami, E., and Donoso, G.: The changing pattern of malnutrition, Ecology Food Nutr. l: 55, 1972. International Planned Parenthood Federation Working Paper No. 5: The relationship between family size and maternal and child health, London, 1970. Niehoff, A., and Meister, N.: Cultural characteristics of breast feeding: A survey, J. Trop. Pediatr. In press. Martin, W. J., Morley, D., and Woodland, M.: Intervals between births in a Nigerian Village, J. Trop. Pediatr. 10: 83, 1964. Tietze, C.: The effect of breast feeding on the rate of conception, Proc. Int. Population Congress, 1971. Forsyth, I.: The role of primate prolactins and placental lactogens in lactogenesis, in Lactogenesis: The initiation of milk secretion parturition, Philadelphia, 1969, University of Pennsylvania Press, p. 195. Cronin, T. J.: Influence of lactation upon ovulation, Lancet 2: 422, 1968. Gioisa, A. R.: Incidence of pregnancy during lactation {n 500 cases, Am. J. Obstet. Gyneeel. 70: 162, 1955. E1-Minawi, M. F., and Foda, M. S.: Postpartum lactation amenorrhea, Am. J. Obstet. Gyneeol. 111: 19, 1970. McKeown, T., and Gibson, J. R.: A note on menstruation and conception during lactation, J. Obstet. Gyneeol. Br. Emp. 61: 824, 1954. Sharman, A.: Ovulation after pregnancy, Fertil. Steril. 2: 371, 1951. Salber, E. J., Feinleib, M., and Macmahan, B.: The duration of postpartum amenorrhea, Am. J. Epidemiol. 82: 347, 1966. Udesky, I. C.: Ovulation in lactating women, Am. J. Obstet. Gynecol. 59: 843, 1950. Lyon, R. A.,~ and Stamm, M. J.: The onset of ovulation during the puerperlum,, Calif. Med. 65: 99, 1946.
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32. Topkins, P.: Histologic appearance of the dometrium during lactation amenorrhea and its relationship to ovarian function, Am. J. Obstet. Gynecol. 45: 48, 1943. 33. Eastman, N.: The effect of the interval between births on maternal and fetal outlook, Am. J. Obstet. Gynecol. 47: 445, 1944. 34. Matthews, D. S.: The ethnological and medical significance of breast feeding, with special reference to the Yorubas of Nigeria, J. Trop. Pediatr. 1: 9, 1955. 35. Baxi, P. C.: A natural history of childbearing in the hospital class of women in Bombay, J. Obstet. Gynecol. 8: 26, 1957. 36. Del Mundo, F., and Adiao, A.: Lactation and child spacing as observed among 2,102 rural Filipino mothers, Phillip. J. Pediatr. 19: 128, 1970. 37. Bont6, M., and Van Balen, H. J.: Prolonged lactation and family spacing in Rwanda, J. Biosoc. Sci. 1: 97, 1969. 38. Jain, A. K., Hsu, T. C., Freedman, R., and Chang, M. C.: Demographic aspects of lactation and post-partum amenorrhea, Demography 7: 255, 1970. 39. Jackson, R. L., Westerfeld, R., Chopra, M. A., Kimball, R. A., and Lewis, R. B.: Growth of "well-born" American infants fed human and cow's milk, Pediatrics 33: 642, 1964. 40. Oomen, H. A. P. C., and Malcolm, S. H.: Nutrition and the Papuan Child, South Pacific Commission Technical Paper No. 11, 1958. 41. Jelliffe, E. F. P.: Weaning multimlxes for the Caribbean, J. Trop. Pediatr. 17: 135, 1971. 42. Jelliffe, D. B., and Maddocks, I.: Ecologic notes on malnutrition in the New Guinea highlands, Clin. Pediatr. 3: 432, 1964. 43. Metz, J.: Folate deficiency conditioned by lactation, Am. J. Clin. Nutr. 23: 843, 1970. 44. Jelliffe, D. B., and Jelliffe, E. F. P.: The effects of famine on the family and on society, in Nutrition in national disasters, Swedish Nutrition Foundation Symposium, Uppsala, 1971, Almqvist & Wiksells, p. 54. 45. Malkani, P. K., and Mirchandani, J. J.: Menstruation during lactation, J. Obstet. Gynecol. Ind. 11: 11, 1960. 46. Hodges, R. E.: Nutriti6n and the pill, J. Am. Diet. Assoc. 59: 212, 1971. 47. Editorial: The pill and folate metabolism, Br. Med. J. 11: 686, 1971. 48. Rose, D. F., and Braidman, I. P.: Excretion of tryptophan metaholltes as affected by pregnancy, contraceptive steroids and steroid hormones, Am. J. Clin. Nutr. 94: 673, 1971. 49. Luhby, A. L., Brin, M., Gordon, M., Davis, P., Murphy, M., and Spiegel, H.: Vitamin Be metabolism in users of oral contraceptives, Am. J. Clin. Nutr. 24: 684, 1971. 49a. Iyengan, L.: Folio acid requirements of Indian pregnant women, Am. J. Clln. Nutr. 3: 13, 1971.
breast-feeding 83
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50. Kora, S. J.: Effect of oral contraceptives on lactation, Fertil. Steril. 20: 419, 1968. 51. Rice-Wray, E.: Oral contraception in Laun America, in Proc. Seventh International Planned Parenthood Federation Conference, Singapore, 1964, p. 367. 52. Kamal, I., Hefnani, F., Choneim, M., Talaat, M., Younis, N., Tagui, A., and Abdalla, M.: Clinical biochemical and experimental studies on lactation, Am. J. Obstet. Gynecol. 105: 324, 1969. 53. Hayden, R. J.: Effect of oral contraceptives on lactation, J. Trop. Pediatr. 2: 59, 19e6. 54. Saxton, G.: A review of research related to family planning in Africa, presented at Ford Foundation Workshop on Need Family Planning in East Africa, Nairobi, Kenya, July, 1970. 55. Jelliffe, D. B., and Jelliffe, E. F. P.: The effect of oral contraceptives on lactation in highly motivated women. In preparation. 56. Lead article: Progestagen--only contraception, Lancet 1: 25, 1971. 57. Saxton, G. A., and Saxton, A. K.: Contraception by jet injection, presented at the Association of Physicians of East Africa and Nairobi, Kenya, June, 1970. 58. Karim, M., Ammar, R., E1 Mahgoub, E1 Ganzoury, F., and Abdou, I.: Injected progestagen and lactation, Br. Med. J. 1: 200, 1971. 59. Abdal Kaden, M. M., Abdal Hay, A., E1Safouri, S., Abdal Aziz, M. Kamal, I., Hefnawi, F., Chonein, M., Talaat, M., Younis, N., Tagui, A., and Abdalla, M., III: Biochemical changes induced in human milk by gestagens, Am. J. Obstet. Gynecol. 105: 978, 1969. 60. Lausas, K. R., Malkani, P. K., Bhatnagar, S., and Lausas, V.: Radioactivity in the breast milk of lactating women after oral administration of 3H-norethynodrel, Am. J. Obstet. Gynecol. 98: 411, 1967. 61. Miller, G. H., and Hughes, L. R.: Lactation and genital involution effects of a new lowdose oral contraceptive on breast feeding and their infants, Obstet. Gynecol. 35: 44, 1970. 62. Curtis, E. M.: Oral contraceptive feminization of a normal male infant, Obstet. Gynecol. 23: 395, 1964. 63. Guttmacher, A.: Factors affecting normal expectance of conception, J. A. M. A. 16: 855, 1956. 64. Jelliffe, D. B., and Jelliffe, E. F. P.: The urban avalanche and child nutrition, J. Am. Diet. Assoc. 57: 111, 1970. 65. Gold, E. M.: Report of current studies of maternal nutrition status in the U.S.A., in Maternal nutrition and family planning in the Americas, Pan American Health Organization Scientific Publication No. 204, Washington, D. C., t970. 66. Chaudhuri, C. : Intrauterine device : Possible role of prostaglandins, Lancet 2: 480, 1971.