The relationship between weight gain in exclusively breastfed babies and maternal diet.

OBJECTIVES: To determine the relationship between maternal nutrition and their breastfed infants' anthropometric measures during the first 14 weeks after delivery.
METHODS: A prospective, observational study, comprising 200 mothers and their infants. The weight, length, and head circumference of the infants and the weight and dietary intake of the mothers were recorded at 6, 10, and 14 weeks.
RESULTS: The relationship between weight gain in babies and calorie intake at 6, 10, and 14 weeks were significant (P value < 0.05). The relationship between weight gain in babies and protein intake at 6 and 10 weeks was not significant (P value at 6 weeks = 0.896, P value at 10 weeks = 0.127) but was significant at 14 weeks (<0.05). Mothers' weight gain during 14 weeks was significant (P value < 0.05). When mothers were distributed into four groups according to their calorie and protein intake for comparison (median value: calorie-2034 kilocalorie, protein- 78.7 grams), the weight, length and head circumference gain in infants and mothers' weight were significantly higher in Group I and Group II compared to Group III and Group IV with P value < 0.05 at 6, 10, and 14 weeks.
CONCLUSIONS: Calorie intake was low in mothers when compared to RDA recommendations. Infants showed lower weight, length, and head circumference gain than WHO Child Growth Standards. There is a direct relationship between the maternal diet and anthropometric measures of their infants. During postnatal period, mothers showed an increase in weight, rather than the decrease that is usually expected. Copyright:

Introduction

Nutritional requirement among lactating mothers is high as compared to nonlactating women. A regular consumption of nutrient-rich diet after lactation may help to replenish body reserves of nutrients utilized during pregnancy and lactation.[12] Any taboos that exist about foods which are actually nutritionally healthy must be discussed.[3] In India, various dietary nutritional supplements are given to lactating women. The present study aims to discuss the nutritional intake of lactating women in the Northern part of Kerala (Malabar) and its influence on the physical growth parameters of their infants during the first 14 weeks after delivery.

Subjects

Inclusion criteria

Women who delivered after completing 37 weeks of gestation (normal delivery/LSCS) with no pregnancy-related complications (Pregnancy-induced hypertension, gestational diabetes mellitus, gestational thrombocytopenia)

Women with no systemic illnesses (e.g. systemic lupus erythematous, immune thrombocytopenic purpura, asthma, seizure disorder etc.)

Babies of term gestational age (completed 37 weeks) and who were exclusively breast fed

Babies without intrauterine growth restriction, congenital anomalies, large for gestational age, and without any significant postnatal problems (neonatal jaundice, birth asphyxia, etc.)

Methods

After obtaining written informed consent for the study, histories were elicited from the mothers. The birth weight, length and head circumference of the babies at birth were noted. The mothers' weight on the third day after delivery were noted. When the mothers and their babies came for the postnatal checkup and immunization at 6, 10, and 14 weeks, 24-hour recall diet of the mothers were noted and their body weight were measured. The anthropometric measures (weight, length, and head circumference) of the babies were also recorded by trained staff at the immunization clinic. The mothers were divided into four groups depending on the median values of calorie and protein intake. The infants' weight, length, and head circumference were compared to the weights of the mothers. Ethics committee approval was obtained. Date of approval – 17/10/2016.

Anthropometric measures

The weight of the babies were measured in kilograms using an electronic weighing scale, with the baby wearing no clothes or diapers. Their lengths were recorded in centimeters, which was measured in the supine position using an infantometer. Their head circumferences (occipitofrontal circumference) were measured using a nonstretchable fiberglass tape and recorded in centimeters. The average weights at birth, 6th, 10th, and 14th weeks, both in male and female babies, were compared with the WHO Child growth standards (50th percentile).[4] In India, WHO Child Growth Standards have been adopted since 2009 for monitoring and promoting child growth and development. This was implemented through the National Rural Health Mission (NRHM) and ICDS.

Dietary assessment

Dietary surveys were done by the 24-hour recall method. Information on the total amount of each preparation was noted in terms of standardized cups. The calorific and nutritive values of different foods consumed by the mothers were estimated using the tables of nutritive value of Indian food and compared with the Recommended Daily Allowance (RDA) for the Indians by the Indian Council of Medical Research 2010 (ICMR).[5]

Results

Of the 200 mother–child pairs included in the study, 82 mothers belonged to the age group of 26–30 years. 140 of the mothers underwent LSCS.

The majority of mothers were from Kozhikode district (177) and 100 of them were Muslims. A total of 91 babies were male.

Difference in weight during 6, 10, and 14 weeks

Table 1 shows that the mean birth weight in males is 3.067 kg (SD = 0.299). The weights at birth, 6, 10, and 14 weeks were significantly lower when compared to the WHO Child Growth Standards (50th Percentile) for males, P value (<0.05) [Figure 1].

Table 1

Weight in males

Weight	Mean	SD	WHO Child Growth Standards (50th Percentile)	t	p
Birth	3.068	0.299	3.3	7.404	<0.05
6 Weeks	4.549	0.471	4.9	7.116	<0.05
10 Weeks	5.527	0.537	5.8	4.849	<0.05
14 Weeks	6.244	0.523	6.4	2.856	<0.05

Figure 1

Comparison of weight in male babies with WHO Child Growth Standards (50th percentile)

Table 2 shows that the mean birth weight of female babies was 3.024 kg (SD = 0.355). The weights at birth, 6 weeks and 10 weeks were significantly lower when compared to the WHO Child Growth percentile (50th percentile) with P value < 0.05. The weight at 14 weeks was higher when compared to the WHO Child Growth standards, but was not statistically significant (P = 0.064) [Figure 2].

Table 2

Weight in females

Weight	Mean	SD	WHO Growth 50th Percentile	t	p
Birth	3.024	0.355	3.2	5.183	<0.05
6 Weeks	4.269	0.451	4.6	7.654	<0.05
10 Weeks	5.139	0.529	5.4	5.154	<0.05
14 Weeks	5.902	0.568	5.8	1.873	0.064

Figure 2

Comparison of weight in female babies with WHO Child Growth Standards (50th percentile)

Difference in lengths at 6, 10, and 14 weeks

Length in males: The lengths at 6 weeks and 10 weeks were significantly lower when compared to WHO growth standards (50th percentile) and was statistically significant (P value < 0.05). The average length at birth and at 14 weeks were lower when compared to WHO child growth standards, but not statistically significant (P value > 0.05) [Figure 3, Table 3].

Figure 3

Comparison of length in male babies with WHO Child growth standards (50th percentile)

Table 3

Length in males

Length	Mean	SD	WHO Child Growth Standards (50th Percentile)	t	p
Birth	49.58	2.044	49.9	1.482	0.142
6 Weeks	54.58	2.338	56.2	6.627	<0.05
10 Weeks	57.82	2.551	59.4	5.914	<0.05
14 Weeks	61.22	2.404	61.4	0.698	0.487

Length in females: The average length at birth was less than the WHO standards (50th percentile), but was not statistically significant (P value > 0.05). The average length at 6 weeks and 10 weeks was lower when compared to WHO standards (50th percentile) with a P value < 0.05. At 14 weeks, the length was found to be more than WHO growth standards, but was not statistically significant [Figure 4, Table 4].

Figure 4

Comparison of length in females with WHO Child Growth standards (50th percentile)

Table 4

Length in Females

Length	Mean	SD	WHO Child Growth Standards (50th Percentile)	t	p
Birth	49.34	2.150	49.1	1.185	0.239
6 Weeks	53.91	2.209	55.1	5.628	<0.05
10 Weeks	56.99	2.216	57.9	4.283	<0.05
14 Weeks	60.31	2.380	59.8	2.233	0.028

Difference in head circumference during 14 weeks

Head circumference in males: The head circumference at birth, 6 weeks, and 10 weeks were lower when compared to the WHO child growth standards which were statistically significant with P value < 0.05. At 14 weeks, the head circumference was lower than WHO growth standards but was not statistically significant (P value > 0.327) [Table 5, Figure 5].

Table 5

Head circumference in males

Head Circumference	Mean	SD	WHO Child Growth Standards (50th Percentile)	t	p
Birth	33.87	1.092	34.5	5.472	<0.05
6 Weeks	37.04	1.039	38.1	9.707	<0.05
10 Weeks	38.85	0.964	39.6	7.448	<0.05
14 Weeks	40.39	1.022	40.5	0.985	0.327

Figure 5

Comparison of head circumference of male babies with WHO Child Growth standards (50th percentile)

Head circumference in females: The average head circumference in females was significantly lower at birth, 6 weeks, and 10 weeks when compared to the WHO standards (50th percentile; P value < 0.05). At 14 weeks, the head circumference was significantly higher than the WHO child growth standards; P value < 0.05 [Table 6, Figure 6].

Table 6

Head circumference in female babies

Head Circumference	Mean	SD	WHO Child Growth Standards (50th Percentile)	t	p
Birth	33.65	1.141	33.9	2.317	<0.05
6 Weeks	36.47	1.077	37.3	8.015	<0.05
10 Weeks	38.24	0.913	38.7	5.290	<0.05
14 Weeks	39.92	1.061	39.5	4.088	<0.05

Figure 6

Comparison of head circumference of female babies with WHO Child Growth standard (50th percentile)

Difference in the weight of mothers during 14 weeks

All the P values are less than the significance level 0.05; the difference in weight of mother during the first 14 weeks after delivery is significant. That is, the weights of the mothers significantly increased during 14 weeks after delivery as compared to their weight mother measured 3 days after delivery. [Table 7, Figure 7]

Table 7

Weight in mother

Weight of Mother	Mean	SD	t	p
Post delivery -3rd day	63.71	9.443
6 Weeks	64.60	9.101	5.889	<0.05
10 Weeks	64.70	9.017	5.245	<0.05
14 Weeks	64.91	8.906	6.254	<0.05

Figure 7

Weight gain in mothers during 14 weeks period after delivery

Calorie and protein intake in mothers

Table 8 shows that the average intake of calorie in all the mothers was 2040 kcal, which was less than the RDA. The average protein intake in all mothers was 77 grams, which was more than the RDA.

Table 8

Comparison between average intake of calorie and protein with recommended daily allowance

	Average	RDA
Calorie	2040 kcal	2500 kcal
Protein	77 grams	74 grams

Figure 8 shows that among the 200 mothers, 34 consumed between 2250–2500 kcal/day, 88 consumed 2250–2000 kcal/day, 70 consumed 1750–2000 kcal/day, and 8 consumed 1500–1750 kcal/day.

Figure 8

Calorie intake in mothers

Figure 9 shows the protein intake among the mothers. 79 of them took 80–90 grams/day, 95 of them took 70–80 grams/day, 24 took 60–70 grams, and 2 of them took 50–60 grams/day of protein.

Figure 9

Protein intake in mothers

Relationship between weight gain in infants and maternal diet at 6 weeks

Table 9 shows that the beta value corresponding to calories was significant as the corresponding P value was less than the significant level (<0.05). The corresponding P value of 0.896 for protein intake, which is greater than the significance level, indicates that protein intake is not related to weight gain.

Table 9

Relationship between weight gain in infants and nutrient intake at 6 Weeks

	Unstandardized coefficients		Standardized Beta	t	p
	Beta	SE
Constant	−1.239	0.310		−3.994	<0.05
Calorie	0.001	0.000	0.577	8.003	<0.05
Protein	0.001	0.005	0.009	0.131	0.896

The regression equation explaining the relation between weight gain and nutrient intake can be written as Weight gain = (0.001 * C) - 1.239

Relationship between weight gain in infants and maternal diet at 10 weeks

Table 10 shows that the beta value corresponding to calorie intake was found to be significant as the corresponding P value (<0.05) was less than the significant level. Since, the corresponding P value (0.127) is greater than the significance level 0.05, protein intake is not related to weight gain.

Table 10

Relationship between weight gain in infants and maternal diet at 10 weeks

	Unstandardized Coefficients		Standardized Beta	t	p
	Beta	SE
Constant	−1.864	0.340		−5.483	<0.05
Calorie	0.002	0.000	0.663	11.31	<0.05
Protein	0.007	0.005	0.090	1.532	0.127

The regression equation explaining the relation between weight gain and nutrient intake can be written as Weight gain = (0.002 * C) - 1.864

Relationship between weight gain in infants and maternal diet intake at 14 weeks

Table 11 shows that the beta values corresponding to calorie and protein intake are found to be significant as the corresponding P values are less than the significant level of 0.05.

Table 11

Relationship between weight gain in infants and maternal dietary intake at 14 Weeks

	Unstandardized Coefficients		Standardized Beta	t	p
	Beta	SE
Constant	-2.038	0.340		-5.996	<0.05
Calorie	0.002	0.000	0.663	12.30	<0.05
Protein	0.015	0.005	0.169	3.143	0.002

The regression equation explaining the relation between weight gain and nutrient intake can be written as Weight Gain = (0.002 * C) + (0.015 * P) - 2.038

Distribution of mothers into groups

Mothers were classified into four groups according to their calorie and protein intakes for comparison. Groups were formed according to the median value calorie and protein intake, which was 2034 kilocalorie and 78.7 grams, respectively [Table 12].

Table 12

Distribution of mothers into groups

	Calorie (kcal)	Proteins (Grams)
Group I	>2034	>78.7
Group II	>2034	<78.7
Group III	<2034	>78.7
GroupIV	<2034	<78.7

Figure 10 shows that 37.0% (n = 74) of the mothers belonged to Group I and 13.0% (n = 26) of the mothers belonged to Group II. Around 11.5% (n = 23) of the mothers belonged to Group III and 38.5% (n = 77) of the mothers belonged to Group IV.

Figure 10

Distribution of mothers into groups

Difference in weight gain in infants between groups

Weight at 6, 10, and 14 weeks: The intergroup difference in weight gain at 6, 10, and 14 weeks was significant (P value < 0.05). The weight gain is significantly higher in Group I and Group II compared to Group III and Group IV [Table 13; Figure 11].

Table 13

Difference in weight gain in infants between groups

Weight gain	Mean	SD	F	p
6 Weeks
Group I	1.502	0.327	22.44	<0.05
Group II	1.625	0.300
Group III	1.384	0.272
Group IV	1.108	0.400
10 Weeks
Group I	2.554	0.417	36.60	<0.05
Group II	2.571	0.366
Group III	2.254	0.304
Group IV	1.904	0.447
14 Weeks
Group I	3.409	0.428	57.29	<0.05
Group II	3.267	0.374
Group III	2.954	0.275
Group IV	2.566	0.432

Figure 11

Comparison of gain in weight at 6, 10, and 14 weeks between groups

Difference in length gain in infants between groups

Length at 6, 10, and 14 Weeks: The intergroup difference in length gain at 6, 10, and 14 weeks was significant. The length gain is significantly higher in Group I and Group II compared to Group III and Group IV [Table 14; Figure 12].

Table 14

Difference in length gain in infants between groups

Length gain	Mean	SD	F	p
6 Weeks
Group I	5.209	1.205	13.89	<0.05
Group II	5.458	1.432
Group III	4.096	0.761
Group IV	4.291	1.072
10 Weeks
Group I	8.735	2.017	16.21	<0.05
Group II	8.654	1.468
Group III	7.065	1.090
Group IV	7.131	1.349
14 Weeks
Group I	12.33	1.571	37.10	<0.05
Group II	12.37	1.205
Group III	10.52	1.285
Group IV	10.12	1.410

Figure 12

Comparison in Length gain at 6, 10, and 14 weeks between groups

Difference in head circumference gain between groups

Head Circumference at 6, 10, and 14 Weeks: The intergroup difference in gain in head circumference at 6, 10, and 14 weeks was significant. The head circumference gain was significantly higher in Group II and Group III compared to Group I and Group IV [Table 15; Figure 13].

Table 15

Difference in head circumference gain between groups

Head circumference gain	Mean	SD	F	p
6 Weeks
Group I	2.984	1.149	4.236	0.006
Group II	3.408	0.667
Group III	3.352	1.262
Group IV	2.727	0.857
10 Weeks
Group I	4.774	1.205	3.843	0.011
Group II	5.273	0.737
Group III	4.987	1.300
Group IV	4.518	0.862
14 Weeks
Group I	6.526	0.988	6.207	<0.05
Group II	6.881	0.994
Group III	6.465	1.136
Group IV	6.055	0.798

Figure 13

Comparison of head circumference gain at 6, 10, and 14 weeks between groups

Difference in the weight of mother between groups

Weight of Mothers at 6, 10, and 14 Weeks: The intergroup difference in weights at 6, 10, and 14 weeks was significant. That is, there was significant difference in weight across groups. The table shows that the difference in weight was significantly higher in Group II and Group I compared to Group III and Group IV [Table 16] [Figure 14].

Table 16

Difference in weight of mother between groups

Weight of Mother	Mean	SD	F	p
6 Weeks
Group I	1.196	2.129	4.187	0.007
Group II	1.865	2.309
Group III	0.565	2.150
Group IV	0.369	1.962
10 Weeks
Group I	1.541	2.560	4.776	0.003
Group II	1.992	3.151
Group III	0.739	2.812
Group IV	0.206	2.379
14 Weeks
Group I	1.808	2.318	4.385	0.005
Group II	2.000	3.082
Group III	0.935	3.046
Group IV	0.423	2.661

Figure 14

Comparison of weight of mothers at 6, 10, and 14 weeks between groups

Discussion

Most of the mothers in this study (41%) belonged to the age group of 26–30 years. Among the infants, most of them were first born (58%). 88.5% of the mothers hailed from Kozhikode. Out of the 200 infants, 54.5% were female babies and 45.5% were males.

All the babies included in the study were term (37 weeks-40 weeks) and adequate for gestational age according to the WHO growth chart. The average birth weight of the babies was 3.044 kg. This is similar to the findings reported by Krishnan, Avabratha, et al.,[6] in South India, which also showed an average birth weight of 3.07 kg.

When the average weight, length, and head circumference at birth, 6 weeks, 10 weeks, and 14 weeks of males and female babies in our study were compared to WHO growth standards, they were found to be lower.

In Kerala, particularly in Malabar region, postpartum care includes special diets, high in carbohydrates, proteins, and fats. Most of the mothers in the study group were nonvegetarians and their average daily intake was 2040 kilocalorie and 77 grams proteins. The calorie intake was found to be lower than the recommended daily allowance, which is 2,500 kcal. Some studies done in lactating women in Kolkata and Haryana also reported lower intake of calories, similar to our study.[78] In one of the recent studies done by Ryan Wessells et al., they found that pregnant and lactating women had difficulty in meeting the nutrient recommendations.[9]

The nutritional status of women in our study, if considered as per calorie intake alone, was directly related to weight gain in their babies during the first 14 weeks. But intake of proteins, though higher in our study population than RDA, did not show any relation to the weight gain in babies during 6th and 10th weeks. However, for reasons that are not clear, the intake of protein had an influence on weight gain at 14 weeks. Protein in mother is needed for body building, repair and maintenance of body tissues, and improving cellular immunity. But as per our findings, whether it influences the weight gain in their babies is not clear.

When the mothers were grouped according to the nutrient intake, it was observed that the babies of mothers who consumed more calories had more weight gain when compared to those who consumed lesser calories, irrespective of the protein intake. These babies had also gained more in length and head circumference. These findings are similar to those reported by Kajale, Khadilkar, et al., which showed that weight gain in infants was higher among the women taking traditional food supplements, which had higher calories and fat, even though those diets were protein deficient.[10] These findings emphasize the need for postnatal counseling to improve nutrient intake in mothers. The counseling can be tailored to individual woman, based on risk factors for poor nutrition such as extremes of maternal age, restrictive dietary practices (e.g. vegetarian), excessive weight gain during pregnancy, and deviations from ideal body weight and multiple gestations.

In the present study, overall, the weight of mothers showed a significant increase after delivery. The increase in weight was more among mothers having higher calorie intake. During postpartum period, in addition to the loss of about 5 to 6 kg due to uterine evacuation and normal blood loss, there is usually a further decrease of 2 to 3 kg through diuresis.[11] A study done by Butte, Garza et al.[12] also showed decreasing trend in the weight of lactating mother during first 4 months postpartum. But in North Malabar region, it is common for almost all postpartum women to keep traditional “dais” during the postpartum period for 40 days. The “dais” cook food, assist in bathing, and take care of the babies; the mothers usually do very little physical activity. This lack of physical activity may be an additional reason for the increase in the body weight in mothers, contrary to other studies.[1112]

In our study, the follow up was done only till 14 weeks post delivery when the mothers came for immunization of their babies, unlike the study conducted by Samano, Martinez et al. where the study duration was for 1 year and weight loss was noted in mothers.[13] It is hence recommended that in our region, mothers and their carers should be educated accordingly in the prenatal and immediate postnatal period, and exercises may be initiated gradually after delivery if medically safe, depending on the mode of delivery, vaginal or cesarean, and the presence or absence of medical or surgical risks or complications.[14]

Thus, it can be concluded that the dietary intake in lactating women has an effect on weight gain in their babies. The study by Van der Pligt et al.[15] in Australia, showed that counseling regarding healthy eating and physical activity is far less during the postpartum period, compared to the advice provided during pregnancy. This may be true in several other parts of the world and seems to be so for lactating women in the North Malabar region of Kerala also. Hence, postpartum women should be counselled about a personalized, balanced diet, including a variety foods such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, and milk. A specific strategy needs to be established to promote women's diet and physical activity during the months following childbirth to enable women to achieve optimal diet and physical activity habits for the sake of their own and their infants' health.

Conclusion

The calorie intake is low in all mothers when compared to RDA recommendations.

Infants showed lower weight, length, and head circumference gain than WHO Child Growth Standards.

There is a direct relationship between the maternal diet and weight gain of their infants.

During postnatal period mothers showed an increase in weight, rather than the decrease that is usually expected.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.