PEDIATRICS (ISSN 0031 4005). Copyright © 1981 by the
American Academy of Pediatrics.
PEDIATRICS Vol. 68 No. 3 September 1 981 435
AMERICAN ACADEMY OF PEDIATRICS
Committee on Nutrition
Nutrition and Lactation
Lactation is a continuation of intrauterine gesta-
tion. In both processes, maternal diet plays an
active role in the provision of nutrients, maternal
nutritional stores and endocrine adaptations serve
to buffer the short-term variations in maternal flu-
tritional intake, blood flow plays an overriding role
in nutrient transfer to the fetus and newborn infant,
and the nutrient demands of the recipient are the
highest of any stage in human development.
Human milk is remarkable in its variability. Re-
cent data suggest that the variability often improves
the nutrient composition as part of a complex adap-
tation to the infant’s specific needs. A comprehen-
sive survey of the literature on lactation and human
milk is provided in two review articles.” 2
NUTRIENTS
Lipids
Milk lipids provide the major fraction of calories
in human milk, yet they are the most variable
constituent.3 Preceding a nursing, the fluid phase of
milk stored within the gland resembles skimmed
milk. During the course of a nursing, the contraction
of smooth muscle launches the fat droplets. Thisdraught reflex is essential for caloric adequacy for
the breast-fed infant.2
Women living under unfavorable socioeconomic
conditions have reduced total milk lipid.46 There is
evidence that supplementing the diets of these
women leads to increased milk fat. Under controlled
metabolic ward conditions, a high-caloric, high-fat
diet can be demonstrated to increase milk fat pro-
duction.7 The distribution of the spectrum of fatty
acids in human milk also is responsive to dietary
changes.7’3
Women who are malnourished also produce an
excess of 12:0 and 14:0 fatty acids.’4 Women ingest-
ing a diet with a high content of polyunsaturated
fat have high levels of unsaturated fat in milk,
especially linoleic acid (18:2).�’� Breast-fed infants
of mothers on a vegetable oil diet have high plasma
levels of linoleic acid (18:2).813
Protein
Colostrum, the milk produced by women in the
first five days post partum, is richer in protein than
milk collected after 30 days of lactation.15’6 The
quantitative and qualitative changes are summa-
rized in Table 1. The “whey” proteins make up the
largest fraction of human milk proteins. By defmi-
tion, they are milk proteins that do not precipitate
in the stomach. Lactofemn and secretory IgA play
a role in the control of susceptibility to gastrointes-
tinal disease in the nursing infant.’ The caseins are
proteins that give milk its characteristic, white ap-
pearance. The micelles of casein coagulate under
the conditions found in the stomach and precipitate
as curds. The older literature indicates that 40% of
human milk protein precipitates under gastric con-
ditions.’5 Recent literature shows that many whey
proteins precipitate with “casein.” 16 The addition
of a skimmed milk supplement sufficient to increase
protein intake of an energy-adequate diet from 25
to 100 gm of protein per day increased milk yield
from severely malnourished women.’7 Total milk
protein concentration was unchanged. The increase
of dietary protein from 25 to 100 gm per day was
associated with increased infant weight gain which
became evident by the third or fourth day and was
sustained throughout a four-week study period.
This study confirmed the findings of previous in-
vestigators.18”9
Carbohydrate
Lactose is the dominant sugar in human milk.’
Synthesis of this sugar takes place at the wall of
the Golgi apparatus. This mechanism effectively
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436 NUTRITION AND LACTATION
traps carbohydrate in the Golgi spaces from which
lactose is released into the alveolar lumen. Although
the concentration of lactose is less variable than
that of other nutrients, the total production is re-
duced in malnourished mothers.’7
Water
Water is by mass and volume the major nutrient
in milk and comprises between 85% and 95% of the
total volume. The total milk volume varies with the
age of the infant and is related closely to maternal
lactose production.’ Folklore says an increased wa-
ter intake increases milk production, but several
investigations have shown that in fact, forcing fluid
intake above that required by normal thirst impairs
milk production.20’2’
Salt
The trapping of lactose within the Golgi spaces
creates an electrochemical difference that is respon-
sible for the transport of sodium and potassium into
milk. The salt concentration of colostrum is higher
than that of mature milk.2224 No relationship has
been demonstrated between maternal salt intake
and human milk sodium concentration.
Calcium and Phosphorus
Milk calcium and phosphorus have mean concen-
trations of 34 and 14 mg/100 ml, respectively.24
Balance studies indicate that the lactating woman
must receive 1.5 to 2 gm of calcium per day to
absorb the 0.3 to 0.5 gm/day secreted in her breast
milk.25 On usual levels of dietary intake, the mother
TABLE 1 . Protein in Human Milk
Fraction Colostrum(mg/mi)
Mature Milk(mg/mi)
Casein . . . 1.9Lactofemn 3.0 1.7a-Lactalbumin 2.2 1.6Secretory IgA 3.0 1.4Lysozyme 0.3 0.4Serum albumin 0.3 0.4
TABLE 2. Minerals in Human Milk
is losing about 250 mg/day more than she is ab-
sorbing.26’27 Older clinical literature documents
cases of osteomalacia and tetany in mothers who
nursed for long periods while on inadequate
diets.m� Clinical reports also document the occur-
rence of rickets in breast-fed infants.25”#{176}’3’ Measure-
ments of total calcium and phosphorus in the
milk of mothers with rachitic infants, however,
revealed no significant alterations in mineral com-
position.25”#{176}’3’ Studies of maternal intakes of dietary
calcium and phosphorus revealed no correlation
with milk concentrations (Table �
Iron
The normal infant at birth has a store of approx-
imately 75 mg of iron per kg.45 Theoretical calcula-
tions and practical experience indicate that this is
adequate to meet erythrocyte iron needs during the
first four to six months of 1ife.4�8 Breast milksupplies about 0.3 mg of iron per liter.36’49 At the
usual rate of intake, many authorities believe that
supplemental iron is essential during the second six
months of breast feeding.�”4�#{176} Supplementing the
diet with iron-fortified cereals during the second six
months of infancy may meet these iron needs.47
Other authors argue that 210 mg of an elemental
iron supplement should be given during the first
year of life to prevent iron deficiency.5’ The iron in
human milk is better absorbed than that from other
milks.�35’5155 Maternal iron stores do not influence
milk iron concentrations.�’47 Iron-deficient anemic
Indian and African women had no reduction in milk
iron, and iron supplements during lactation did not
increase milk iron.32’47
Zinc
Colostrum has a zinc concentration of 4.6 mg/
liter37; at 6 months of age, the concentration in
human milk falls to 0.9 mg/liter�; and, at 1 year of
age, average milk zinc is 0.45 mg/liter.� At 6 months
of age, breast-fed infants have serum and hair zinc
concentrations equivalent to those of adults. For-
mula-fed infants have lower serum and hair zinc
Mineral Concentration
ThroughoutFacilitated
BioavailabilityEffect of Maternal Mineral
Intake on Milk ContentLactation
Sodium Declines2224 Unknown None (unpublished)Calcium Unchanged24 Unknown None32IronZinc
Unchanged24Declines37’�
Facilitated�’35Facilitated39’40
None�’1’None36’�
CopperManganese
Unchanged37Declines�42
UnknownUnknown
None�’4’Yes36
Selenium Unknown Unknown UnknownIodine Declines43 Unknown Yes43Fluoride Unknown Unknown None�
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AMERICAN ACADEMY OF PEDIATRICS 437
concentrations despite intakes up to 5.8 mg/liter
from cow’s milk formula.� This observation con-
firms earlier experiments that indicate zinc is better
absorbed from human milk than from cow’s milk.
This is because of a 50% better bioavailabiity of
zinc in human milk (Table 2).�#{176}Dietary investiga-
tions indicate that a majority of North American
women do not meet the 25 mg/day standard of
intake suggested by the Recommended Dietary Al-
37,� No difference in milk zinc concentra-
tions was detected when a group of women who had
intakes in excess of the Recommended Dietary Al-
lowances were compared with a group of women
whose diet provided one-half this amount.� No
relationship has been detected between maternal
serum, hair, and milk zinc concentrations.37�
Copper
When the infant is between 6 and 12 weeks of
age, human milk has an average copper concentra-
tion of 0.3 mg/liter.37’49 Milk copper concentration
averages 0.5 mg/liter during the first weeks of lac-
tation.� There is no decrease in concentration after
2 weeks of age.37 No relationship between maternal
dietary intake and milk copper concentration has
been observed.3�
Manganese
Human milk contains approximately 20 �tg/liter
of manganese.37 With the possible exception of an
elevated level at two weeks of lacthtion,�’42 the
concentrations of manganese are constant, even
after 1’/2 years of milk production. There is no
relationship between maternal diet and serum level,
hair concentration, or milk content of American
women. A relationship between diet and milk man-
ganese levels has been reported in Finnish women.36
Selenium
Selenium is of interest in infant nutrition because
of its role in the requirement for vitamin E. The
mean concentrations in human milk have been
reported to be 30 pg/liter in Germany,� and 20 �g/
liter in the United States.37 The selenium in human
milk was three times higher than that in commercial
infant formulas.�
Iodine
Human milk contains a total of about 100 �zg of
iodine per liter during mature milk production. The
use of iodized salt by the mother was associated
with levels of twice this concentration. Colostrum
has an iodine concentration of about 200 jzg/liter.43
There is a milk-to-plasma gradient for inorganic
iodine that is greater than i0.�
Breast-feeding for six months has been reported
to mitigate the impact of congenital cretinism on
physical and mental development.�#{176} This is ex-
plained largely by the transfer of thyroid hormones
in breast milk. The studies of the Montreal screen-
ing program for congenital hypothyroidism have
not confirmed that breast-feeding provided protec-
tion in 12 infants with thyroid insufficiency diag-
nosed and treated by 6 weeks of age.6’
Fluoride
The fluoride concentration of human milk col-
lected on the fourth and fifty days post partum
averages 50 gig/liter. This is one half the concentra-
tion found in whole cow’s milk.� When milk col-
lected from women living in a low fluoride area was
compared to milk from women in an area where the
drinking water was fluoridated, the mean concen-
trations did not differ significantly. Fluoridation of
drinking water is not associated with a major in-
crease in human milk fluoride concentrations.
Vitamin D
Fifty years ago, rickets was observed commonly
in breast-fed infants who were seen at public hos-
pitals in the United States.62 This continues to be
true among mothers who, because of social or reli-
gious practices, do not drink vitamin D-fortified
milk.63 A daily supplement of approximately 1,000
lU/day of vitamin D given to lactating mothers
prevents rickets in breast-fed infants. The effect is
in proportion to the total quantity of vitamin D
ingested by the lactating mother (Table 3)#{149}62
Early bioassays could not document nutritionally
adequate quantities ofvitamin D in human milk.71’72
Current advances in vitamin D chemistry have
revealed that cholecalciferol and 25-hydroxychole-
calciferol are in the lipid fraction of human milk. A
sulfated fraction also is present in the aqueous
phase.7�76 Japanese investigators report that water-
soluble vitamin D sulfate is as potent as the lipid-
soluble form in the prevention or healing of rickets
in rats.73 They further report that the total vitaminD potency in human milk was bioassayed to be 750
lU/liter, most of which was accounted for by the
sulfated form of the vitamin. This work requires
confirmation before new recommendations can be
made regarding vitamin D supplementation of the
breast-fed infant.
Vitamin K
Hemorrhagic disease of newborn infants is a dis-
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TABLE
Vi-
tamin
In Malnour-
ished
Yes25”'2UnknownUnknown
Unknown
In WellNourished
UnknownNone””'5
Yes””””
Yes7#{176}
438 NUTRITION AND LACTATION
order associated with prolonged prothrombin times
and reduced blood prothrombin levels (Table 3). It
is prevented effectively by the administration of 100
;ig of vitamin K soon after delivery. The mother
does not provide for the vitamin K requirements of
the fetus or her nursing infant (Table 3).�”� Cow’s
milk formula contains vitamin K. Newborn infants
who receive a cow’s milk formula have a reduction
in prothrombin time (and therefore increased pro-
thrombin level) equivalent within 24 hours to that
observed in infants receiving vitamin K supplement.
The breast-fed infant or the infant who is fasted in
the perinatal period must rely on a vitamin K
supplement to restore the prolonged prothrombin
time observed at birth.77
Vitamin A
Colostrum is rich in vitamin A. Despite adequate
maternal vitamin A intake and serum concentra-
tion, the milk content of the vitamin decreases
during the course of lactation from 2,000 to 250 �ig/
liter�’78’79 The vitamin A concentration of colostrum
or milk can be increased about fourfold by acute
loading of the mother with excessive supplements
(Table 3) � The ratio of milk/serum concentra-
tion is approximately 0.6. The effect of increased
dietary vitamin A reflects the dependence of milk
concentrations ofalimentary intake. Efforts to build
up the liver reserves by prenatal supplementation,�
by a long-term supplement,�#{176} or by administration
3. Fat-Soluble Vitamins in Human Milk
Recogniz- Effect of Maternal Effect ofable Supplements Dietary
Clinical Intake onDeficiency Milk
Content
UnknownNone”65
Yes”9
Unknown
D Yes25”'2K Yes”’A UnknownE Unknown
of carotene”�’69 did not increase milk vitamin Aconcentrations.
Vitamin E
Vitamin E concentration is greatest in colostrum,
averaging 13.3 mg/liter,79 and it is approximately
equal to maternal plasma levels.8’ Concentrations
in milk decrease to half at two weeks post partum
and to one-fourth at one month post partum.79
Breast-fed infants have an increase in vitamin E
blood level from 3.8 to 14.6 mg/liter during the first
six days of life. Concentrations thereafter parallel
the maternal serum levels. Unless a supplement is
provided, formula-fed infants have a persistence of
low serum levels for at least six months.8’
Vitamin C
Higher concentrations of vitamin C exist in the
plasma and in leukocytes of cord blood than are
found in the mother. This is true even when mater-
nal blood levels are extremely low.82 Balance studies
carried out during lactation suggest that the mother
provides milk ascorbic acid at her own expense.�
The older literature claims that scurvy is rare in
breast-fed infants (Table 4).”' Seasonal fluctuations
in milk concentration reflect the availability of vi-
tamin C in the diet.�”’79’�” Milk concentrations reflect
the intake of ascorbic acid among subjects on a
reduced intake33’�’9’ The subjects respond to ad-
ministration of vitamin supplements in proportion
to the intake; milk levels increase from 24 to 61 mg/
liter when the supplement provided is 200 mg/day.�”
Thiamine (B1)
Infantile beriberi has been observed in breast-fed
infants when unfortified, machine-milled rice was
the main cereal in maternal diets. The addition of
thiamine provided dramatic relief to the infants.�
Milk thiamine concentrations from women on this
diet reveal a drastic reduction in vitamin content.”7
TABLE 4. Water-Soluble Vitamins in Human Milk
Vitamin Recognizable Effect of Maternal Effect ofClinical
Deficiency
Supplements Dietary Intake
on Milk
ContentIn Malnour- In Wellished Nourished
Ascorbic acid Rare�’ Yes�” No”� Yes””Thiamine Yes85 Yes�’ Yes””�” Yes87Riboflavin Unknown Yes�” Yes”�”'””'””'”#{176} Yes””9’Niacin Unknown Yes”� Yes�””'” Yes”’Pantothenic acid Unknown Yes33 No”� Yes9’Pyridoxine Unknown Yes33 Yes”’ UnknownBiotin Yes92 Yes� No”” UnknownFolate Unknown Yes� No* No”3”'’Cyanocobalamin Rare95 Yes�’ Yes”’ Yes”5
* M. R. Thomas, S. M. Sneed, C. Wei, et a!, unpublished data, 1981.
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AMERICAN ACADEMY OF PEDIATRICS 439
In normal women, milk thiamine is increased from
an average 20 pg/liter in colostrum to 140 �tg/liter
in mature milk.””’�’ Concentrations of milk from
poorly nourished women have shown the same in-
crease during lactation.89 In both well nourished �“‘�“
and poorly nourished mothers.� milk concentra-
tions respond to thiamine supplementation (Table
4)#{149}86��
Riboflavin (B2)
Riboflavin resembles thiamine in the relationship
between dietary intake and milk vitamin concentra-
tion. The concentration in colostrum is approxi-
mately 200 �tg/liter compared to 370 �tg/liter in
mature milk.”�97 The concentrations tend to fall to
lower levels with prolonged lactation.”9 The concen-
tration in milk reflects the average dietary
intake.””9’ The administration of riboflavin either
as a loading dose”” or as a continuing supplement”�’8”
results in the elevation of milk concentrations as
high as 2,000 �.tg/liter (Table 4).�”’�#{176}
Niacin
Milk niacin levels are reduced in colostrum to 750
�tg/liter and increase during the first two weeks of
lactation to three times this level. In mature milk
production, dietary niacin intake influences milk
concentration (Table 4),91 The bioavailabiity of
niacin can be reduced on a corn diet and will result
in reduced milk concentrations despite apparently
adequate maternal vitamin intake.”’� Supplemen-
tary intakes of the vitamin increase milk concentra-
tion acutely”7 and produce sustained effects.”�”'9
Milk contains sufficient tryptophan which is con-
vertible to niacin to protect the infant against niacin
deficiency.
Pantothenic Acid
Human milk pantothenic acid levels increase to
an average concentration of 2 to 3 mg/liter during
the first weeks of lactation.97 In poorly nourished
women with milk concentrations averaging 1 mg/
liter, supplementary vitamin intake has increased
milk content in proportion to the intake (Table
4)#{149}3391 In well nourished North American women
with basal levels of 3 mg/liter, no increase wasdetected after supplementations.”
Pyridoxine (B6)
Fetal pyridoxine levels, as reflected in cord blood,
are about three times the levels found in the ma-
ternal circulation. The pyridoxine level in colostrum
is equivalent to maternal blood levels; mature milklevels are 16 times maternal blood levels.””’� Milk
pyridoxine levels in poorly nourished populations
are lower than those observed in the United
States.33M Supplementary pyridoxine given to these
poorly nourished women resulted in a twofold in-
crease in milk concentrations, 80 to 160 jig/liter
(Table 4).� In North American women, supplemen-
tation with pyridoxine resulted in a statistically
significant increase in milk content from 204 to 237
jig/1iter.�
Biotin
The biotin content of human colostrum is low; it
increases from 1 to 8 jig/liter in mature milk.97
There appears to be a lower content of this vitamin
in the milk of poorly nourished women33 than in the
milk of most North American women.”' Supplemen-
tation of biotin in women with poor nutritional
status resulted in an increase from 1.5 to 5 jig/liter
(Table 4).�’ No effect was observed from supple-
mental biotin�’ in American women whose initial
levels averaged 8 jig/liter.
Folate
Folic acid levels are low in human colostrum, 0.5
jig/liter, and they increase in mature milk.97 Poorly
nourished women with low milk folate levels aver-
aging 2 jig/liter responded to a vitamin supplement
with a peak content at 5.6 jig/liter.33 In lactating
women who develop megaloblastic anemia, folic
acid is excreted preferentially in milk. This affords
protection of the infant hemoglobin concentration
in severe maternal anemia.93”’ In North American
women with milk folate concentrations of 50 jig/
liter, the administration of an oral “one-a-day” sup-
plement was not associated with increased milk
concentrations. (M. R. Thomas, S. M. Sneed, C.
Wei, et al, unpublished data, 1981).
Cyanocobalamin (B12)
Maternal levels ofvitamin B12 are reduced during
the last trimester of pregnancy, but fetal and cord
blood concentrations remain high. Administration
of labeled cyanocobalamin to the mother resulted
in transfer of the vitamin to the fetus. Stores of
maternal liver B,2 are not transferred across the
placenta.’#{176}#{176}Milk vitamin levels range from 50% to
90% of the maternal serum level. The high extrac-
tion occurred in vegetarian women who had lower
serum vitamin levels. Milk vitamin B,2 levels, how-
ever, were not lower than those in nonvegetarian
women control subjects.’#{176}’ When women from a
poorly nourished community received a vitamin B12
supplement, milk concentration increased only
from 0.8 to 1 jig/liter (Table 4).� When well nour-
ished women received a “one-a-day” supplement,
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0 28 56 84 1128
7
I(9Li
4
3
EU
I��55(9zLi
50
0
Figure. Growth of normal breast-fed infants during first weeks of life. These infantsreceived some supplements of infant foods or formulas after 28 days of age. Charts providea standard for normal growth during first weeks of life when transition to mature milkproduction �
28 56 84 112 0 28 56 84 112
AGE (days) AGE (days)
440 NUTRITION AND LACTATION
milk concentration increased significantly from 0.6
to 1 jig/liter. No change in serum vitamin levels
could be detected in these normal women.�
FAILURE TO THRIVE
Growth is the most practical assessment of nutri-
tional adequacy in childhood. The percentile clas-
sification of lengths and weights of normal breast-
fed infants has been developed by a group of inves-
tigators from Iowa. The data from these measure-
ments on 178 normal, full-term infants are given in
the Figure. As with the more familiar charts, loss of
percentile channels is a cause for careful surveil-
‘#{176}‘
Failure to grow “normally” may be a transient
phenomenon associated with either infantile or ma-
ternal factors, some of which are poorly understood.
Severe failure to thrive in breast-fed infants is a
recognized clinical entity. Case reports indicate that
the infants usually are brought for treatment when
approximately 30 days old, and they have obvious
malnutrition. Weight at the time of examination
commonly is 20% lower than birth weight. The
infants are said to feed poorly but to appear satis-
fled. Chemical determinations commonly reveal a
reduction in total serum protein and elevated serum
urea nitrogen. The infants respond to supplemental
feedings or maternal support designed to augment
milk production, such as increased maternal caloric
intnke.’#{176}�’#{176}”One of the common characteristics of
these severely ill infants is a lack of pediatric su-
pervision between delivery and the time of the
examination. These case reports emphasize the
need for frequent contact between the mother andphysician during the period of transition to mature
milk production. The initial visit for health evalu-
ation should be two weeks after discharge, and at
appropriate intervals thereafter.
SUPPLEMENTATION
Maternal diet and nutritional status influence the
quantity and quality of human milk. Lactation also
has a profound influence on maternal nutrient phys-
iology. The unique biologic advantages of human
milk justify the promotion of lactation as the nor-
mal method of infant feeding. The variabifity of
milk quality and quantity justify an ongoing assess-
ment of the infant’s weight gain and state of hydra-
tion by the pediatrician as part of the promotion
and supervision of the extension of normal gesta-
tion.
The nutritional needs of the mother during lac-
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AMERICAN ACADEMY OF PEDIATRICS 441
tation have been summarized by the National Acad-
emy of Sciences in the Recommended Dieta�y Al-
lowances and are shown in Tables 5 and 6.’#{176}”An
increase in intake is recommended for lactating
women to meet the needs for milk production and
protect against deficiencies in maternal nutrients.
When related to caloric intake, the increased re-
quirement is not uniform. A woman at nutritional
risk probably could not meet these recommended
intakes by increasing her usual diet. The milk of
women at nutritional risk may have low nutrient
composition; a vitamin supplement can be demon-
stated to improve the quality of their milk. In North
American women consuming a contemporary diet,
milk composition varies; but low nutrient values are
rare and the administration of vitamin supplements
is probably unnecessary. A deviation from a normal
dietary pattern should lead to a reassessment of
nutrient needs and dietary counseling, and/or a
prescription of multivitamin-multimineral supple-
ments adequate for the special circumstances.
The breast-fed infant requires a vitamin K sup-
plement during the newborn period. There also are
arguments in favor of providing vitamin D and
fluoride as supplements during the first six months
of life; disagreement, however, remains about
whether these nutrients must be provided to all
breast-fed infants. During the latter half of the first
year of life, iron (either in a supplement or in
fortified infant cereals) should be recommended.
Supplementary calories in the form of infant foods
TABLE 5. Daily Requ irements of Lactating Women*
Nutrient Recommended Allowance
Energy +500 kcalProtein +20 gmCalcium +400 mgPhosphorus +400 mgMagnesium +150 mgIron +30-60 mgZinc +10 mgIodine +50 �g
* Calculated from Recommended Daily Allowances.’#{176}”
TABLE 6. Daily Requirements of Lactating Women*
Nutrient Recommended Allowance
Vitamin A +400.0 � REVitamin D +5.0 �gVitamin B +3.0 mg TEVitamin C +40.0 mgThiamin +0.5 mgRiboflavin +0.5 mgNiacin +5.0 mg NEVitamin B6 +0.5 mgFolacin +100.0 jigVitaminB,2 +1.0 jig
* Calculated from Recommended Daily Allowances.’#{176}”
Abbreviations used are: RE, retinol equivalents; TE, to-copherol equivalents; NE, niacin equivalents.
and infant formulas should be started when weight
gain and other findings indicate that the milk sup-
ply is not adequate to meet the needs of continuing
rapid growth.
REFERENCES
COMMIrFEE ON NUTRITION
Lewis A. Barness, MD, Chairman
Peter R. Daliman, MD, Vice-Chairman
Homer Anderson, MD
Platon Jack Collipp, MD
Buford L. Nichols, Jr, MD
W. Allan Walker, MD
Calvin W. Woodruff, MD
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American College of Nutrition. New York, Alan R Liss,Inc, 1981, pp 109-146
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