For decades, prenatal vitamins have been a cornerstone of pregnancy care, recommended by healthcare providers to support the intense physiological changes experienced by both mother and baby. Now, a new category of supplements has emerged: postnatal vitamins. These supplements aim to provide crucial nutrients to breastfeeding women during the postpartum period.
Nutritional Needs in the Postpartum Period
Adequate nutrition during the postpartum period is crucial to ensure optimal health of mother and baby. Breastfeeding mothers are both recovering from their pregnancy and delivery and producing milk for their newborn - two incredibly demanding physiological processes. Breast milk provides complete nutrition for an infant, and is composed of protein, lipids, carbohydrates, and all essential vitamins and minerals. Ideally, breastfeeding mothers should obtain most of their required vitamins and minerals by consuming a balanced, varied, and nutritious diet. However, mothers may benefit from supplementation of some of the various components that are secreted into their breastmilk.
Key Vitamins and Minerals for Lactating Women
Several vitamins and minerals play a vital role in the health of both mother and baby during lactation. Postnatal supplements often contain higher levels of these nutrients compared to prenatal vitamins.
- Vitamin A: Needed for vision, immune function, and proper cellular differentiation and signaling. The recommended dietary intake of Vitamin A for lactating women ages 19-50 is 1300 mcg, which is substantially higher than the recommended intake for pregnant women which is 770 mcg. This is to compensate for the relatively high amount of Vitamin A that is secreted into breast milk.
- Vitamin E: An important antioxidant. The recommended dietary allowance for Vitamin E for lactating women ages 14-50 is 19 mg, as compared to 15 mg for pregnant women. Similar to Vitamin A, this increased requirement is to compensate for the Vitamin E that is secreted into breast milk.
- Vitamin D: A fat-soluble vitamin necessary for proper absorption of calcium and bone mineralization. Breast milk contains inadequate levels of Vitamin D and all infants require supplementation to ensure proper bone mineralization. This is particularly important for women with dark skin, those who live in locations with little sunlight, and those with a diagnosed Vitamin D deficiency. The concentration of Vitamin D in breast milk does not respond proportionally to increased maternal intake, and there is conflicting evidence of the effects of maternal supplementation on Vitamin D levels in breast-fed infants. Some research has reported that very large maternal doses of vitamin D that exceed the safe upper limit of 4000 IU per day can provide adequate vitamin D to the infant through breast milk. However, caution is warranted on consuming these large doses, as excess intake can cause toxicity.
- Vitamin K: Necessary to facilitate proper blood clotting. Similar to Vitamin D, breast milk contains inadequate levels of Vitamin K for infants. Thus, all newborns are given a Vitamin K injection at birth to prevent hemorrhage.
- Vitamin C: Responsible for synthesizing collagen and is necessary for proper wound healing. Vitamin C is also secreted in breast milk - thus, a higher dietary intake is recommended for lactating women to make up for this loss.
- Calcium: The recommended daily intake of calcium is the same for lactating mothers as it is for pregnant and non-pregnant women at 1000 mg. During pregnancy, calcium availability in the body increases through increased absorption of calcium from foods, increased mobilization from bones, and decreased calcium loss through the kidneys. These changes are sustained during lactation.
- Iron: The recommended dietary amount of iron for lactating women ages 19-50 is 9 mg, which is less than the recommended amount for pregnant women (27 mg), and nonpregnant women (18mg). This is due to lactational amenorrhea, the temporary period in which a postpartum woman is breastfeeding and not menstruating, thus reducing her iron loss. For women who experience excessive blood loss during delivery or postpartum hemorrhage, iron-deficiency anemia during the postpartum period is extremely common. Take supplemental iron for six to eight weeks after delivery, to build up your iron stores again. Look for at least 27 mg of iron each day. Most gummy and chewable vitamins do not contain iron (as a safety precaution). If taking a gummy or chewable prenatal, you will also need an iron supplement.
- Iodine: A mineral necessary for proper production of thyroid hormone, which is crucial for brain development in the developing fetus. The neural tube is the embryological precursor to the central nervous system, which is composed of the brain and spinal cord.
- Vitamin B12: Plays an important role in an infants’ neurological development. Infants of lactating mothers who are deficient in Vitamin B12 may develop anemia or exhibit neurological abnormalities. Vitamin B12 levels are reduced in the breast milk of mothers who follow vegan diets or other restrictive diets that exclude meat, chicken, fish or dairy. Similarly, Vitamin B12 levels can be reduced in mothers with pernicious anemia, an autoimmune disorder that limits Vitamin B12 absorption, and mothers who have undergone gastric bypass surgery. For women with these unique needs, it is particularly important to supplement Vitamin B12 while lactating.
- Zinc: The recommended dietary allowance of zinc in lactating women is 12 mg, and 11 mg in pregnant women. This is to compensate for the zinc that is secreted in breast milk.
- Selenium: The recommended dietary allowance of selenium in lactating women is 70 mcg, and 60 mcg in pregnant women.
- Omega-3 Fatty Acids (DHA): Omega-3 long-chain polyunsaturated fatty acids (LCPUFA), particularly docosahexaenoic acid (DHA), are important for proper development of the brain and retina. Maternal intake of omega-3 LCPUFA through fish consumption has been shown to increase the concentrations of omega-3 LCPUFA in breast milk. However, certain species that are likely to have high levels of mercury should be avoided, as these are harmful to the developing nervous system. Currently, there is not enough research on omega-3 supplementation while breastfeeding and its subsequent effect on infant cognitive development. DHA is an essential fatty acid, meaning we can't make it ourselves," says Gering. "Research shows that infants have enhanced motor, cognitive and visual development if their mom consumes DHA. It's found in most prenatal vitamins."
Postnatal Supplements vs. Prenatal Supplements
Nutrient requirements for lactating mothers are unique. Typically, women are told to continue their prenatal supplements during the postpartum period. While this may be appropriate for certain nutrients, it may be inappropriate (providing either too much or too little) for other nutrients. For example, the average prenatal supplement does not provide adequate levels of Vitamins A, E, or C to meet the recommended daily requirements for lactating women and may provide too much iron for a mother whose iron stores have recovered from delivery. There are substantial differences in the contents of prenatal and postnatal supplements. As evident in Table 2, there is high variability both between the components of prenatal and postnatal supplements and within these groups themselves. Breastfeeding poses nutritional demands that are distinct from pregnancy. Postnatal supplements may be a good option for breastfeeding mothers to ensure they are obtaining adequate nutrients.
Postpartum Weight Retention: A Significant Health Concern
Postpartum weight retention (PPWR) refers to the weight retained after giving birth compared to prepregnancy weight. In the US, a significant portion of women and birthing people experience PPWR. Studies show that 50-75% of patients weigh more than their prepregnancy weight at 12 months postpartum with half retaining at least 10 pounds and a quarter at least 20 pounds . Furthermore, those with PPWR tend to weigh on average 15 pounds more at 2 years after delivery compared to prepregnancy . Among those with prepregnancy obesity, about 50% still experience PPWR at 6 months postpartum, and this risk increases if gestational weight gain exceeded recommended levels .
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Several factors increase the likelihood of PPWR exceeding 20 pounds, including race/ethnicity (African American or Hispanic), age < 30 at delivery, public insurance, lower physical activity levels, job loss during pregnancy, and exceeding gestational weight gain recommendations . Cesarean delivery is also associated with PPWR as patients who have a cesarean birth are 30% more likely to retain at least 10 pounds at 1 year postpartum than those who deliver vaginally .
Health Risks Associated with PPWR
PPWR affects the outcomes of future pregnancies. Patients whose BMI is at least 2-3 kg/m2 BMI units greater in a successive pregnancy than the previous pregnancy are more likely to develop hypertensive disorders of pregnancy, gestational diabetes, have large for gestational age infants, require cesarean delivery, and experience stillbirth, even if they remain in a normal BMI category .
For patients whose PPWR results in obesity (BMI ≥ 30 kg/m2), there are additional potential complications which include spontaneous abortion, congenital malformation, obstructive sleep apnea, carpal tunnel syndrome, endometritis, and venous thrombosis . Patients with obesity who lose weight between pregnancies (starting weight lower in successive pregnancy than the index pregnancy) have a 30% reduction in the risk of a large for gestational age infant; the effect of weight loss on decreasing other adverse obstetric outcomes is less clear .
Postpartum weight retention is also associated with an increased risk for long-term cardiovascular disease. A large Danish population-based study demonstrated that patients whose weight was at least 1 kg/m2 BMI unit higher than their prepregnancy weight were 25% more likely to develop chronic hypertension by 18 months postpartum . For patients with normal or underweight prepregnancy BMI and a PPWR of at least 2 kg/m2 BMI units at 18 months postpartum, they were 50% more likely to have cardiovascular disease diagnosed . Regarding the offspring’s health, a child of a patient with an interpregnancy weight gain of at least 3 kg/m2 BMI units is almost 20% more likely to be overweight or obese at 4-5 years of age .
Given the potential health impacts of postpartum weight retention, supporting mothers in their weight loss goals is crucial for both their well-being and that of their children.
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Strategies for Postpartum Weight Loss
While there is no single best approach, several strategies can help mothers achieve their weight loss goals.
Physiologic Weight Loss
Independent of the balance between caloric intake and energy expenditure, there is an expected baseline weight gain (or in some, weight redistribution) due to several physiologic changes of pregnancy. The uterus hypertrophies (averaging 2 pounds at term), blood volume and extravascular fluid volume increase (adding 5 to 7 pounds), breasts enlarge (1 to 3 pounds), and there is the weight contribution from the products of conception themselves (7 to 8 pounds for the fetus, 2 pounds of amniotic fluid, and 1 to 2 pounds of placenta) . Therefore, postpartum weight loss intuitively begins immediately following parturition with the expulsion of the fetus, placenta, and amniotic fluid. Uterine involution, loss of lochia, and postnatal diuresis lead to the loss of an additional 5 to 15 pounds, with the majority of physiologic weight loss happening in the first 6 weeks postpartum .
Exercise
When combined with caloric restriction, regular physical activity reduces PPWR. In a comprehensive meta-analysis by Dodd, et al., 27 randomized-controlled trials comparing postpartum weight change in patients enrolled in a lifestyle intervention (dietary instruction, exercise regimen, or both) versus standard care were evaluated . An average weight loss of 4 pounds and 3 pounds was seen in trials with dietary intervention alone (N = 75) and physical activity intervention alone (N = 93), respectively. However, in trials with combined diet and exercise interventions (N = 1156), the average postpartum weight loss seen was 5.5 pounds in all-comers and 6 pounds in patients who were overweight or obese at the start of the index pregnancy (N = 667). Patients with combined diet and exercise instruction were also more likely to maintain their weight loss at 12 months post-delivery than control groups .
Avoiding a sedentary lifestyle and engaging in regular physical activity are recommended for most patients in the postpartum period. Guidance from the U.S Department of Health and Human Services and the World Health Organization advise postpartum patients to engage in at least 150 min of moderate-intensity aerobic exercise per week, spread throughout the week . Additional benefits of regular postpartum physical activity include boosting energy, promoting better sleep, preventing or reducing the symptoms of postpartum depression, restrengthening the abdominal wall muscles to reduce the incidence of diastasis recti abdominus, and reducing lumbopelvic pain .
Determining the safest time to return to the suggested level of weekly physical activity postnatally depends on several factors, including mode of delivery, degree of perineal trauma, incontinence, severity of anemia, presence of medical or surgical complications, and personal preferences. For patients with uncomplicated deliveries, physical activity can be resumed very shortly after delivery with light-intensity, progressing to moderate over time. While there is limited data evaluating the effect of an early return to activity on pelvic floor function, data from a randomized controlled trial of patients undergoing reconstructive pelvic surgery demonstrated fewer urinary and prolapse symptoms in those allowed to return to activity at their own pace versus those with restricted activity for 3 months postoperatively . Kegel pelvic floor strengthening exercises can be initiated 2 to 14 days after delivery in patients without obstetric anal sphincter injury or episiotomy; these exercises can be deferred if the exercise incites pain. Early ambulation reduces the time to return of bowel function, risk of thrombosis, and postpartum length of stay . Use of stairs at home with assistance while moving at a deliberate pace is allowable. Regarding lifting weights, data are lacking to guide safe upper weight limits. As only 50-60% of the abdominal fascia strength is restored at 6 weeks postpartum, a cautious approach is sensible. ACOG offers a general recommendation to temporarily restrict the amount of weight lifted to no more than that of the newborn .
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Lactation
The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months followed by continued breastfeeding with complementary foods for at least 2 years . Lactation is an energy intensive state which theoretically could elicit a net-negative balance contributing to postpartum weight loss. However, studies vary on whether breastfeeding without additional caloric restriction or exercise is enough to combat postpartum weight retention .
The Dietary Guidelines for Americans (2020-2025) recommends an additional 330 cal in the first 6 months postpartum and 400 cal between 6 and 12 months postpartum compared to prepregnancy needs for lactating patients . The Calculator for Health Care Professionals provides guidance for daily nutrient and calorie thresholds to meet nutritional requirements based on age, body mass index, activity level, and pregnancy or lactation status . In patients that have established a consistent breastmilk supply and are motivated to lose weight, providers can prescribe a diet that is 500 fewer calories per day (the energy output of breastfeeding), maintaining a minimum of at least 1800 cal per day. This should elicit a moderate weight loss of 1 pound per week, which over 4 months, can help a patient return to their prepregnancy weight without negatively impacting infant growth .
During lactation, adhering to a balanced diet including all classes of macronutrients is crucial for maintaining the composition and quantity of breast milk produced. Several of the fad diets popularized in the US media (e.g., very low carbohydrate, paleolithic, very low fat) can lead to nutritional deficiencies in lactating women and should be avoided . Meal plans should emphasize nutrient-dense whole foods such as fruits, vegetables, legumes, whole grains, and healthy fats . Patients opting for a vegan diet should have assessment and repletion of folate, vitamin B12, iron, zinc, choline, iodine, and EPA/DHA .
Pharmacotherapy
There are numerous medications with US Food and Drug Administration approval for the treatment of overweight and obesity. The preferred medications for weight loss are glucagon-like peptide 1 (GLP-1) receptor agonists with or without dual agonist action for gastric inhibitory polypeptide (GIP). GLP-1 receptor agonists are anorectics which act on the hypothalamus and have several effects: reduced appetite, increased satiety by inhibiting gastric emptying, inhibited glucagon release, decreased insulin resistance, and stimulated glucose-dependent insulin secretion. Other classes of weight loss drugs include amphetamine derivatives, naltrexone-bupropion, and pancreatic lipase inhibitors. For best effect, weight loss medications should be used in conjunction with diet, lifestyle modification, and physical activity. Most patients will experience a rebound weight gain upon medication discontinuation, and thus continued lifelong use is recommended .
Postpartum patients may be candidates for medical treatment of weight loss if they have a BMI of at least 30 kg/m2 (or BMI 27-29.9 kg/m2 plus metabolic disease) and have not achieved a 5% weight loss despite 6 months of a comprehensive lifestyle intervention. One randomized controlled trial found that for patients who experienced gestational diabetes, postpartum treatment with an 84-week course of liraglutide (a GLP-1 receptor agonist) plus metformin was more efficacious than metformin monotherapy in reducing body weight, central adiposity, and insulin resistance (notably, this trial was limited by a high attrition rate in both arms) .
Intentional weight loss and the use of the weight loss medication is not recommended in pregnancy due to adverse effects and safety concerns. Animal studies have demonstrated teratogenic effects with GLP-1 agonists, including reduced embryonic survival, delayed ossification, skeletal variations, and poor fetal growth . Human data of periconception GLP-1 use has shown a 6% incidence of major congenital malformations in offspring . Amphetamine derivatives are also not recommended in pregnancy and are associated with an increased risk for orofacial clefts, fetal growth restriction, and stillbirth. Lastly, medications that reduce intestinal fat absorption may lead to fat-soluble vitamin deficiencies and their associated risks for pregnancy. Timing for discontinuation of weight loss drugs prior to conception depends on the half-life; for GLP-1 agonists, they should be discontinued 2 months prior to conception .
There is limited data regarding medical weight loss and lactation. It is not known if GLP-1 agonists, GIP agonists, pancreatic lipase inhibitors (e.g., Orlistat), or amphetamine derivatives (e.g., Phentermine) are present in breast milk. Naltrexone-bupropion and its metabolites are excreted in breast milk; while naltrexone has not been shown to have any negative infant effects, there are case reports of possible seizures in partially-breastfed infants exposed to bupropion. Topiramate is often combined with Phentermine and is present in breast milk; diarrhea, somnolence, irritability, hypertension, sleep changes, tremor, vomiting, and weight loss have been reported in infants exposed to it.
The Role of a Healthy Postpartum Diet
During the postpartum period, your body needs time and energy to heal. Nutrition helps the healing process. And, if you've chosen to breastfeed, your diet affects your baby, too. A healthy postpartum diet includes lean proteins, whole grains, low mercury fish and lots of fruits, veggies and water.
Safety Considerations for Weight-Loss Supplements During Breastfeeding
Diet pills may be tempting to help you shed pounds quickly, but taking weight-loss supplements while breastfeeding likely isn't safe for you or your child. Weight-loss supplements often claim to help burn fat, regulate appetite, speed metabolism or improve nutrition to ultimately help you slim down, according to the Cleveland Clinic. Food and Drug Administration (FDA), and in fact, there's little scientific evidence to show they work at all, per the Mayo Clinic. And not only is it unlikely that these supplements will help with weight loss, but some of these products can also harm your health due to side effects and hidden ingredients, according to the Mayo Clinic.
If you're wondering whether you should take weight-loss pills while breastfeeding, the short answer is probably not (the same goes for taking diet pills while pregnant). Diet supplements (yes, even the "natural" ones) may have side effects that can affect you and your child, as it's possible to pass potentially harmful ingredients to your baby via breastmilk, according to the Cleveland Clinic.
Per the National Institutes of Health (NIH), potential side effects include:
- Headaches
- Difficulty sleeping
- Muscle or bone pain
- Increased heart rate
- High blood pressure
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Abdominal cramps
- Gas
- Heartburn
- Vertigo
- Weakness
- Anxiety
- Jitteriness
- Kidney stones
- Liver damage
Certain ingredients in diet supplements are explicitly discouraged if you're breastfeeding. For instance, 5-Hydroxytryptophan is a component of certain weight-loss pills that may not be safe for your baby, according to Mount Sinai. Some of these products also contain prescription drugs without listing them on the label, per the Mayo Clinic, which can produce even more unexpected side effects and potentially harm you or your child.
Additionally, the downstream effects of certain diet pills may not be safe while you're breastfeeding. For example, many supplements contain caffeine, which acts as a diuretic and eliminates fluid from your body, per the NIH. Staying well-hydrated is important while you're breastfeeding, so losing too much fluid can jeopardize healthy lactation, according to the Children's Hospital of Philadelphia (CHOP).
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