I'm a big pro-nursing advocate, and lately I've been wondering if nursing after gastric bypass will be just as
hard easy as it was last time. I nursed my third child exclusively, from birth to age 3.
(Edited to add, the post bariatric surgery baby was born October 2006, I nursed her for five weeks and gave up. I had serious trouble with getting a decent milk supply.)
Coincidentally the third child weaned abruptly with my stay in the hospital for the actual weight loss surgery, but she was by then only comfort nursing and we were more than ready to end it. Even though we had a rough beginning, and it took a long time for me to establish a good milk supply, it worked out in the end, and she was by far my most normal-weight baby. I formula fed the first two children after very short failed attempts at nursing, and they were both overweight as infants also.
I've been wondering, will I be able to establish a normal milk supply? Will I be able to provide enough vitamins, namely B-12 with the supplementation I'm recieving through B-12 injections? Will my state of anemia cause problems - or will it gradually improve once the baby is born, and not cause problems? Will I be able to safely lose the baby weight I've gained while nursing and ingest enough calories to maintain my milk supply?
These are things that any pregnant post weight-loss surgery patient needs to be aware of. There are potential problems, but it seems most if any can be avoided or treated with monitoring up front.
A question from- http://depts.washington.edu/nutrpeds/faq/pregnancy/bypass.htm
"A lactation consultant referred a 3 week old infant not back to discharge weight. Mom had a gastric by-pass 3 years ago. The pediatrician wants to supplement with formula about 4 times per day and is also supportive of herbal supplements (e.g., fenugreek, mother's milk tea, brewer's yeast) for Mom or prescribing Reglan. With lactation consultant support they got a good pump, also a starter SNS, and 2 different feeding cups, and nipple shield. Still weight gain was marginal. Could the mother's gastric by-pass be a contributing factor in this problem?" This situation of a breastfeeding woman who has had a gastric bypass is probably rare.
The answer from: http://depts.washington.edu/nutrpeds/faq/pregnancy/bypass.htm
However, there have been a few cases of significant nutrition problems in infants with mothers who had gastric bypass. Two case studies were of infants who were diagnosed with vitamin B12 deficiency and megaloblastic anemia (1,2). This was secondary to decreased vitamin B12 in the breast milk; the mothers had subclinical vit B12 deficiencies. In another case, the 4 month old infant was diagnosed with failure to thrive (3). Creamatocrit analysis of the breast milk indicated only 39% of the normal fat content of breast milk, and thus the energy level of the milk was reduced. In the case described here, there may be infant factors contributing to the lactation problems, but they seem to be addressed appropriately by the lactation consultant. There may also be stress or emotional feelings in the mother that is contributing. In any case, frequent monitoring, including signs of vitamin B12 deficiency in the mother and infant, is indicated. A creamatocrit may also be useful at some point.
According to Kellymom.com:
Who needs vitamin B12 supplements?
By Kelly Bonyata, IBCLC
Infants of well-nourished mothers with adequate vitamin B12 intake do not need vitamin B12 supplements.
It is recommended that mothers who do not eat animal proteins or who are otherwise at risk for vitamin B12 deficiency get adequate amounts of vitamin B12 during pregnancy and lactation via supplements or fortified foods.
Since vitamin B12 (cobalamin) is widely present in foods from animal sources, dietary deficiency is rare except in those eating a strict vegan diet (no fish, meat, poultry, eggs or dairy products). Most infants, children and adults in the United States get the recommended amounts of vitamin B12. If a breastfeeding mother has an adequate B12 status, her baby will receive sufficient amounts of vitamin B12 via her milk. A simple blood test can diagnose current vitamin B12 deficiency.
In the US, the DRI for vitamin B12 for adults is 2.4 µg per day, 2.6 µg during pregnancy, 2.8 µg during lactation; the DRI is proportionally less for children. The DRI has a significant margin of safety built in. Unlike other B vitamins, small amounts of vitamin B12 are stored in the liver so daily consumption is not necessary.
Who is at risk for vitamin B12 deficiency?
- Anyone who is on a strict vegetarian or vegan diet (no fish, meat, poultry, eggs or dairy products) and is not getting adequate amounts of vitamin B12 through supplements or fortified foods.
- Anyone who has had gastric bypass surgery, has pernicious anemia or has certain gastrointestinal disorders and is not getting adequate amounts of vitamin B12 through supplements or fortified foods. Some medications may also decrease absorption of vitamin B12.
- An infant born to a mother who has been a strict vegetarian or vegan for at least 3 years and who is vitamin B12 deficient herself.
- An infant born to a mother who is vitamin B12 deficient due to any other dietary or medical reason.
- An exclusively breastfed baby of a woman who is vitamin B12 deficient.
According to Nutrition During Lactation (Hamosh 1991, p. 157-58), a full-term infant of a well-nourished mother will be born with a store of vitamin B12 sufficient to meet his needs for about 8 months. If the mother is not vitamin B12 deficient herself, then her milk is an excellent source of vitamin B12 and is more than sufficient for baby’s needs through the first year.
There is evidence that babies born to vitamin B12 deficient mothers have low stores of vitamin B12 at birth. Studies have shown that mothers who are vitamin B12 deficient have low levels of vitamin B12 in their milk.
Breastfed infants may develop clinical signs of vitamin B12 deficiency before their mothers do. Vitamin B12 deficiency may develop in the breastfed infant by 2 – 6 months of age, but may not be clinically apparent until 6 – 12 months. Signs and symptoms of vitamin B12 deficiency in infants include vomiting, lethargy, anemia, failure to thrive, hypotonia (low muscle tone), and developmental delay/regression.
There have been anecdotal reports of low milk supply in vitamin B12 deficient mothers, which improved when the B12 deficiency was corrected. Mothers with pernicious anemia are also at higher risk for thyroid problems, which can affect milk supply.
For mothers who are vitamin B12 deficient, increasing vitamin B12 intake increases the amount of the vitamin in her milk."
What are the caloric demands for a nursing mom? Some moms worry that they won't be able to physically eat enough calories to maintain a solid milk supply after gastric bypass.
Nutrient needs during lactation depend primarily on the volume and composition of milk produced and on the mother's initial nutrient needs and nutritional status. Among women exclusively breastfeeding their infants, the energy demands of lactation exceed prepregnancy demands by approximately 640 kcal/day during the first 6 months post partum compared with 300 kcal/day during the last two trimesters of pregnancy (NRC, 1989). In contrast, the demand for some nutrients, such as iron, is considerably less during lactation than during pregnancy.
I'm trying to find good
information regarding breastfeeding after weight loss surgery. There
doesn't seem to be much, if any, out there. Today, I found this
article, for dieticians:
Breast-feeding After Bariatric Surgery
By Julie Stefanski, RD, LDN, CDE
Vol. 8 No. 1 P. 47
Lactating mothers and their infants have special nutrition
needs. Can women with limited food intake after bariatric surgery meet
An outpatient dietitian at Bellevue Woman’s Hospital in Niskayuna,
N.Y., Karann Durr, RD, CDN, searched the Internet, consulted personal
resources, and contacted other RDs for advice and information. She was
left with nothing substantial. In the end, she and her hospital’s
lactation consultant were forced to make professional guesses on the
issue—lactation after gastric bypass surgery.
Durr explained, “I had to take the evidenced-based practice
guidelines for lactation and the nutrient recommendations for gastric
bypass and put the two together. Basically, because this is new, people
are reluctant to venture there.”
The human body can adapt to the changing demands of lactation by
increasing nutrient intake, improving absorption, decreasing excretion,
or using tissue stores. For the patient who has undergone bariatric
surgery, it is questionable whether the body’s natural adaptations for
lactation can overcome the physiological changes the surgery has
According to Jeanne Blankenship, MS, RD, an expert in bariatric
surgery and reproductive health from the University of California,
Davis Medical Center, “We need to promote breast-feeding to this
population—more than 80% of the women who have surgery are of
child-bearing age. The numbers are going to keep going up.”
Blankenship further elaborates that “we do know that obese women are
less likely to initiate breast-feeding and, if they do, they are less
likely to make it to the major marks—three and then six months—let
alone one year. What we don’t know is if a woman who was previously
obese behaves like an obese woman or like a normal-weight woman in
terms of lactation. There are definitely success stories, but I think a
lot of these women fall through the cracks.”
Gail Hertz, MD, IBCLC, pediatrician and certified lactation
consultant, points out that not all healthcare practitioners may be
familiar with the long-term effects of bariatric surgery. “The average
pediatrician probably isn’t aware of the impact of gastric bypass on
nutrition because typically our patients aren’t undergoing the
procedure themselves. In our practice, we do ask breast-feeding mothers
about any breast reconstruction or reduction, but if the mother doesn’t
volunteer information about her past surgeries, we may not know.”
surgeries are classified as restrictive, malabsorptive, or a
combination of the two. Operations such as vertical banded gastroplasty
(VBG) and gastric banding aim to limit the amount of food that can be
ingested and reduce the emptying rate of the stomach.
The Roux-en-Y gastric bypass (RYGB), bilio-pancreatic diversion
(BPD), and the now uncommon jejuno-ilial bypass combine restriction and
malabsorption. The RYGB utilizes a 30- to 50-milliliter pouch, formed
by surgically separating the stomach. A gastrojejunostomy is created by
anastomosing the stomach to the distal end of the jejunum. The BPD
utilizes a subtotal gastrectomy to create a larger pouch than the VBG
or RYGB. As a more complicated surgery, the small intestine is divided
to create a gastroileostomy, bypassing the lower stomach, duodenum, and
jejunum and leaving only the distal ileum for nutrient absorption.
Due to the surgical alteration of the gastrointestinal tract using
the RYGB and BPD approaches, patients require perpetual supplementation
to meet minimal nutrient needs. If eating habits are too restrictive
after VBG or laparoscopic banding, deficiencies may occur.
Habits Under Investigation
a survey of bariatric practitioners and you will find varied vitamin
and mineral prescriptions. In terms of pregnancy and lactation, the
general nutrient recommendations may not meet increased requirements.
Additionally, compliance with recommended supplements can be poor.
Total weight loss averages 25% to 35% of initial body weight at 18
months after surgery. Pregnancy is not recommended within the first 18
to 24 months after surgery due to the active weight loss occurring.
After 24 months, weight loss has stabilized or regain may begin to
occur. Several articles have been published that address the needs of
pregnancy after gastric bypass.
Calorie consumption has been shown to be approximately 1,100
calories per day at one year post-op and 1,300 calories per day at 18
months. Post-gastric bypass patients’ diets have also been shown to be
low in nutrients vital to pregnancy and lactation, such as iron,
calcium, and folate. Actual vitamin deficiencies, other than vitamin
B12 and folate, have yet to be quantified. Due to the absence of
standardized follow-up of patients after surgery, there is inadequate
information regarding the effects of bariatric surgery on many aspects
of health.3 Women who have achieved healthy pregnancies face challenges
when it comes to breast-feeding. Limited data exists to help
practitioners guide mothers in the right direction.
Will the Maternal Diet Affect Milk Production?
milk is a symphony of nutrients that varies between mothers and changes
with lactation duration or even time of day.16 In studies of lactation
during famine conditions, malnourished mothers were able to produce
sufficient breast milk and support normal growth in their infants.17,18
In several instances, maternal nutrition stores suffered as breast milk
quantity and quality remained adequate.
“It is definitely true that there is no reason that they can’t
breast-feed if their diet is adequate. Compliance with vitamins and
minerals is important. It really depends on the type of surgery, how
long it has been since surgery combined with their breast-feeding
history, age, and, of course, all the factors that affect
breast-feeding in the general population,” explains Blankenship. When
combining breast-feeding with a history of bariatric surgery, there are
several key nutrients practitioners must focus on to achieve success in
the breast-feeding relationship.
lactation, the dietary reference intake is 500 calories higher than
guidelines intended for women who are not breast-feeding. This
recommendation of 2,700 calories per day is based on energy needed for
milk production, energy mobilized from fat stores, and estimated
metabolic rate. It is assumed that 66% of calorie needs will be
provided by oral intake and 34% will come from fat stores gained during
In one study, participants consumed approximately 1,500 calories per
day for the first six months of lactation. Although these women had not
undergone weight-loss surgery, their low calorie intake did not affect
breast milk production and prolactin levels remained within normal
important steps in vitamin B12 absorption are affected by RYGB.
Deficiencies have been discovered in 30% to 70% of patients one to nine
years after RYGB. Hemoglobin or mean corpuscular volume levels may not
reveal this deficiency. Secretion of hydrochloric acid may be nearly
absent in the surgically created pouch. With decreased acid and pepsin
exposure, vitamin B12 can not be cleaved from foods such as meat, milk,
and eggs. B12’s attachment to glycoproteins and subsequent coupling
with intrinsic factor is also hindered by the pathophysiology of the
Mothers who are B12 deficient during pregnancy may give birth to
infants with subnormal B12 stores. Further depletion may occur as the
infant is undersupplied via human milk from a B12 deficient mother.
In a case study presented in 1994, a 10-month-old, exclusively
breast-fed infant was found to have a vitamin B12 deficiency. Two years
prior, the mother had undergone bariatric surgery. Although the mother
was asymptomatic, she was also deficient in vitamin B12.
In a similar scenario, a 12-month-old, exclusively breast-fed infant
of a semivegetarian mother, presented with developmental delay,
macrocytic anemia, low folate and B12 levels, a positive urinary
methylmalonic acid peak, and a high homocystine level. The infant’s B12
deficiency was corrected parenterally. Two months later, the mother
revealed she had undergone bariatric surgery six years earlier.
Although the mother consumed vitamin B12 and iron supplements, the
vitamin B12 level of her milk was found to contain only 42 picomoles
per liter compared with a normal level of 184 to 812 picomoles per
primarily by the proximal one third of the small intestine, folate
absorption must now occur in a smaller surface area under modified
conditions. Folate deficiency has been documented in up to 40% of
patients after RYGB and is of great concern in regard to the onset of
neural tube defects. Both serum folate levels and red blood cell counts
should be evaluated to detect deficiencies and patients supplemented
to the circumvention of the duodenum in RYGB, the primary absorption
site for calcium is omitted. Passive diffusion of calcium must occur
along the remaining small intestine. Serum levels may remain stable, as
calcium is leeched from maternal stores.6 Reductions in maternal bone
content occur during the first three to six months of lactation, but
this loss is replaced in later lactation and after weaning. Breast milk
calcium secretion does not appear to depend on the current calcium
intake of the mother, nor does the intake of phosphorus, magnesium, or
sodium. Maternal intake during pregnancy may predetermine the calcium
content of breast milk after delivery.
ideal amount of calcium and vitamin D gastric bypass patients need to
maintain stable parathyroid hormone and 25-hydroxyvitamin D has yet to
be determined. Typical amounts of 800 to 1,000 international units
(IUs) are provided upon initiation. Infants may be influenced more by
the vitamin D status of the mother during pregnancy and by the amount
of sun exposure received rather than by vitamin D levels in breast
milk. Human milk naturally contains low levels of vitamin D.
Additionally, there is little evidence to suggest that lactation
increases vitamin D needs in the mother.
Guidelines have previously encouraged two hours per week of direct
sun exposure or 30 minutes per week wearing only a diaper to stimulate
adequate vitamin D production in the exclusively breast-fed infant.41
The American Academy of Pediatrics now recommends that infants less
than 6 months old be kept out of direct sunlight to limit UVA light
exposure and suggests that “all breast-fed infants receive at least 200
IU of vitamin D per day beginning in the first two months after
intake of sufficient sources of heme iron, a reduction in the acidic
environment required to release heme iron, and changes in absorptive
surface area impact iron stores. Iron deficiency may occur in up to 50%
of patients after RYGB, especially in women who are still menstruating.
Amenorrhea from sustained lactation
can actually benefit women as decreased blood loss via the menstrual
cycle can boost depleted iron stores.
Although breast milk is a poor iron source, iron from human milk is
better absorbed than formula. Lactoferrin, a whey protein connected
with infant immune response, has been found in greater concentration in
breast milk from iron-deficient women. It has been hypothesized that
this increase may help protect the infant from iron deficiency.
Some evidence suggests that standard multivitamins will not prevent
a deficiency after bariatric surgery. Women who have undergone
restrictive procedures may not require additional iron beyond the
A deficiencies have only been reported to occur after biliopancreatic
diversion in the nonpregnant population.15 Vitamin A levels should be
tested early in pregnancy and patients should be counseled to consume
adequate amounts of vitamin A via food. Women who oversupplement may be
at risk of consuming intakes of preformed vitamin A in amounts greater
than 5,000 IUs, which may cause birth defects. Fat-soluble vitamin
content of breast milk has been found to be minimally impacted by
recent intake of the mother.
of adequate water-soluble vitamin levels in the body, especially
thiamine, requires a continuous supply in the diet. Even patients who
have undergone restrictive procedures can develop a deficiency if oral
intake is inadequate.
Vitamin C, niacin, thiamine, riboflavin, and vitamin B6 levels in
human milk are greatly influenced by the mother’s diet. In studies of
maternal supplementation of water-soluble vitamins, vitamin levels
increased in human milk and then leveled off. High doses of vitamin B6
should be avoided as production of prolactin may be inhibited.
consensus has been reached on the extent to which protein energy
malnutrition may develop after gastric bypass surgery. A protein intake
of 65 grams per day is recommended for the first six months of
breast-feeding. Patients’ diets and lab values should be evaluated, and
patients should be encouraged to focus on high-quality protein sources
to meet minimal guidelines.
According to Kelly O’Donnell, MS, RD, CNSD, nutrition support
specialist with the University of Virginia Medical Center, “Our average
patient, two to three years out, is consuming about 900 to 1,000
calories per day. Specific food choices are one of the most essential
points to stress. Snacks become very significant. Choosing low fat,
high protein choices, which are good calcium sources, are very
comprises one half of breast milk calories and is highly variable. The
total lipid content of human milk is not affected by daily intake in
normal mothers, although it has been correlated with maternal fat
Breast milk contains arachidonic acid (ARA) and docosahexaenoic acid
(DHA), which have been associated with improved cognition, growth, and
vision in children.55 Some experts recommend supplementation of ARA and
DHA in the diets of both pregnant and lactating mothers, especially for
those with limited diets.
A patient who failed to follow nutrition guidelines provided after
her gastric bypass several years earlier suffered from anemia during
her pregnancy and gave birth to an infant weighing little more than 5
pounds. Growth milestones were not reached and, upon assessing the
mother’s breast milk at four months postpartum, an analysis of the fat
content, or creamatocrit, revealed a low mean fat and calorie content.
After the mother supplemented with formula, adequate growth was
displayed in the infant at 6 months of age.
Should We Wait for Weight Loss?
concern with reinitiating rapid weight loss after birth may cause some
women to forgo breast-feeding altogether. Blankenship points out that
there may be significant psychological issues to consider. “Many
pregnancies are unplanned and women just want to get back to the weight
loss. Patients have misconceptions about weight loss during lactation
and they want to be able to drastically cut calories.”
Regardless of the fact that many studies have reviewed the impact of
lactation on weight maintenance, true consensus has not been reached.
Greater weight loss has been shown in breast-feeding mothers vs. women
who choose to use formula, while other studies have been inconclusive.
Gradual weight reduction, in amounts no greater than 1 pound per
week, does not appear to negatively affect the quantity or quality of
breast milk produced, though environmental pollutants stored in
maternal fat tissue may be released into breast milk with extended
Vitamin and Mineral Supplements
of childbearing age should be advised to consume a prenatal vitamin
containing 1 milligram of folate, 350 to 500 micrograms of crystalline
vitamin B12, plus calcium citrate in amounts of 1,200 to 1,500
milligrams and vitamin D. Patients who have had gastric bypass surgery
should consume 40 to 65 milligrams iron in the ferrous form daily.8,37
Some guidelines suggest that, during pregnancy, the prenatal vitamin
should be given in addition to, not instead of, a daily multivitamin.10
The consumption of two prenatal vitamins may not be advisable because
some combinations may exceed vitamin A and iron guidelines.37
Maternal lab values, including CBC, albumin, folate, vitamin B12,
calcium, phosphorus, and 25-dehydroxy-vitamin D, should be tested
during pregnancy and after birth to detect deficiencies and
supplemented accordingly. Infants should be evaluated for appropriate
growth, adequacy of B12, calcium, and folate levels throughout the
duration of breast-feeding.
Careful Monitoring Equals Success
Woodard, MSN, WHNP, nurse practitioner with the University of Tennessee
Medical Center, emphasizes the importance of educating both patients
and practitioners. “The challenge for healthcare providers lies in
educating women pre- and post-operatively regarding the ramifications
of stopping vitamin supplements, which a good number do. Lifelong B
vitamin and calcium supplementation is a must for these patients,
especially those planning a pregnancy. Pediatricians and pediatric
nurse practitioners, as well as women’s healthcare providers, should
also be made aware of these dangers.” The increased risk of nutritional
deficiencies induced by bariatric surgery, coupled with the demands of
lactation, requires careful monitoring by knowledgeable professionals
familiar with both bariatric surgical procedures and the nutritional
needs of lactating mothers and their infants.
— Julie Stefanski, RD, LDN, CDE, is a clinical dietitian, adjunct professor, and freelance writer in York, Pa.