Breastfeeding

Concerns for breastfeeding mothers whilst fasting in Ramadaan vary depending on the age of the baby, previous breastfeeding experience, any solid intake of the child, and the number of children being breastfed. Mothers with twins, or with older babies who rely heavily on breast milk have the greatest demand on lactation as do mothers with exclusively breastfed babies.

Even with the presence of such demands, it is anticipated that fasting is within the means and abilities of the vast majority of women. General advice is that fasting whilst breastfeeding is safe, particularly for women whose babies are not exclusively breastfed, and that fasting should not be readily left.

It is a myth that inadequate fluids and food intake create a poor milk supply. The most common causes of poor milk supply when babies are small are due to infrequent feeds, a poor latch, positioning, or sucking problems on the baby’s part[1]. Malnutrition is rarely a cause and “even in societies where women are on marginal diets, most are able to produce breast milk in amounts that are adequate for good infant growth.”[2]

It is not uncommon for women to have a perceived supply problem when nourishment levels are at least adequate, both when fasting and not. There is evidence that fasting does not decrease breast milk, even though 22% of women report a perceived decrease in one particular study.[3] It is very rare for women actually to fail to lactate.

This is not to say that fasting can, and may well, alter breastfeeding habits, particularly early on in Ramadaan when the body is adjusting to new patterns. It can take a few days, perhaps even up to two weeks, for some women and their babies to adjust to a Ramadaan fasting routine after which it is much easier. Some women may not need any time to adjust, or will have adjusted by fasting in Sha’ban.

It is comforting to know that fasting will not result in a breastfed baby gaining less weight or not growing properly, even for exclusively breastfed babies.[4] There is no evidence demonstrating that fasting whilst breastfeeding a baby of any age has adverse consequences on breastfeeding itself, or on the child.

As for difficulties for the mother, women may worry about dehydration or not being able to meet the nutritional demands of their children. It is easy, and natural, to switch adequate fluid intake to night time when fasting. Prentice et al. (1984) found lactating Gambian women fasting in Ramadaan for 14.5 hours had normal levels of hydration where temperatures are around 30 degrees. The women “superhydrated” themselves at night by drinking about 2 litres more than other women at night.[5]

This may have been because it is a common belief that by drinking lots we can protect our milk supply. However, “evidence suggests that lactating women can tolerate a considerable amount of water restriction and that supplemental fluids have little effect on milk volume… there appears to be no justification for emphasizing high fluid intake as a way to improve milk production.”[6]

We would still encourage women to drink plentifully throughout the night as this advice is for women in general and not specific to fasting. Food abstinence won’t affect milk supply but dehydration, when severe, will. If for some reason you cannot or have not taken in too much extra fluid this should not affect your milk supply. Note that the body utilises water not only from beverages but also from foods, accounting for a sizeable percentage of fluid intake. All foods naturally have a high percentage of water and some fruit and vegetables contain lots of water, such as  cucumbers and lettuce.

A second interesting finding with the Gambian mothers were some changes in their breast milk which have also been reported in other cultures. Milk volume was not affected but milk composition did change. Fasting affects the biochemical/nutrient content of breast milk to a certain extent as the body makes several metabolic adaptations whilst fasting to ensure that milk production is not affected.

The “micronutrient” content of breast milk is affected, such as mineral levels, but the “macronutrient” content is not.[7] Macronutrients are proteins, carbohydrates and fat that are needed in large quantities for growth and energy. Fasting doesn’t change these in breast milk but affects levels of micronutrients that are only needed in small quantities, such as magnesium, zinc and potassium. Even twenty hours of fasting has no discernible effect on the output of milk, milk secretion rate or its macronutrient composition.[8] “Breast-milk is incredibly resilient, and can retain its major nutrients even during fasting.”[9]

Considering the evidence indicating that fasting does not harm breastfeeding mothers and their children, the remaining factors to consider when making decisions on fasting are fairly simple. First and foremost, the mother’s health is a consideration as is illness, such as fever, that automatically exempts any person from fasting, or pregnancy-related conditions where medical advice is not to fast.

A second, equally important, consideration would be the child’s health. If a baby is ill and the mother has concerns about her child’s levels of hydration, or if a child remains distressed to a degree that could harm them, or the mother is unsure of their nutrient intake then these needs must be weighed to determine how much of a worry this is and if it is significant, if it is a fear, then fasting can be left.

The balancing of fear for oneself, or for the baby, is essentially down to each individual and if the fear for adverse health outcomes or the continuation of breastfeeding is present then a woman can break her fast.

It is also important to consider any other forms of nutrition a baby has. If formula milk is given in addition to breast milk, or there is an expressed milk store that can be used, or if the baby eats solids then these need to be factored in when deciding whether to fast. All of these additional forms of nutrition obviously reduce the demands on lactation during fasting and any worries about milk can be settled easily by choosing the alternate feeding choice in most cases.

Please note that formula milk is not a substitute for breast milk[10] and we are not encouraging its use or its adoption during Ramadaan in order to facilitate fasting. However, if women are already giving their babies formula milk and have no intention to cease doing so then they have the option of offering formula milk as a complement. For example, if the baby usually has one bottle feed at night and the family intends to continue formula milk irrespective of Ramadaan then the mother would have the option of switching the bottle to the day-time nap instead and continue to fast and breastfeed at night.

We also would not advise increasing bottle feeds and reducing breastfeeding in order to manage fasting. Reducing breastfeeding could eventually result in a decrease in milk supply as breast milk is made upon a demand basis[11]. The more breast milk a baby takes, the more the mother produces and so introducing more formula feeds, or more solids, will lessen milk production. The speed at which this happens varies immensely between women.

Having said this, there is no harm in increasing solid intake gradually to some degree whilst maintaining existing levels of breastfeeding. This is not to encourage anyone to reduce breastfeeding, but to provide women with some assurance that their babies’ nutritional needs are met, to bring peace of mind and to support fasting. There is some evidence that despite increasing a child’s food intake in Ramadaan when the mother is fasting, breast milk is not reduced.[12]

Also, if women express milk, or have a frozen store of breast milk that is intended for later use then Ramadaan may be a time to utilise that store. Again, we would not advocate a habit of expressing and storing milk as there are benefits to feeding directly from the breast whenever possible, but if this is something that helps, particularly perhaps towards the evening before breaking fast, then it can be used to make things easier rather than leaving breastfeeding or fasting.

Finally for babies that also eat solids, based upon exclusive breastfeeding practices where solids are introduced at a minimum age of 6 months and increased to 3 meals a day by the time a baby reaches 12 months, there does not seem to be a warrant for abandoning fasting when babies are aged around 12 months onwards. No perceivable serious risk should be present unless the baby is still heavily reliant on breast milk.

Of course, even when a baby takes solids, breast milk is most often the primary source of nutrition during the first year.[13] This does not automatically exempt mothers with babies under 12 months, especially if solids were started earlier[14], or when breast milk is replaced with formula. Furthermore, as stated earlier, most women with exclusively breastfed babies will also be fine if they choose to fast.

We do realise that breastfeeding during Ramadaan may be disruptive but the inconvenience of having to breastfeed more at night, a reduction in daytime feeds, and moderate agitation in the child or mother are not serious reasons not to fast. They do not fulfil the conditions of fear of harm to oneself or to the baby that permit women not to fast.

We should continually bear in mind the health of the baby and the mother when making decisions on fasting, highlighting that if breastfeeding itself is perceived to be at risk, even if the health of the child or the mother is fine, this is sufficient as a reason for exemption. Breastfeeding presides over fasting.

Finally, we would also encourage all mothers to continue suckling frequently during Ramadaan, both whilst fasting and after having broken fast, during the day and at night, and even when they feel that their breasts are ’empty’. Babies don’t suckle purely for nutritional needs to be met and one very important reason for suckling is stimulation of an adequate milk supply. Milk removal is what drives supply.

Lactating women are always making milk. Milk production actually only slows down or speeds up. When there is more milk in the breast, less milk is produced. When the breast is empty, milk production is increased. It is a supply that is based upon demand.

The emptier the breast, the faster the body makes milk to replace it and so it is a good idea to nurse whilst fasting and immediately after breaking fast, ensuring that one breast is drained before switching to the other and offer both breasts in order to further encourage milk supply. The fuller the breast, the more milk production calms down, and so there is no need to wait to feel full before feeding.

Breastfeeding is an incredible process and one that is a moral obligation upon every mother. Its importance and value is signified by the concessions that apply to any breastfeeding mother who can leave fasting in order to ensure continued and successful, healthy breastfeeding.

This is to be balanced with the fact breastfeeding in itself does not automatically and universally exempt women from fasting. The bar for permission to leave fasting is set high and from the discussion above, fasting is safe.

[1] Hill, P. (1992) Insufficient milk supply syndrome. NAACOG’s Clin Issues; 3(4):605-13.

[2] World Health Organization. Not enough milk. Division of Child Health and Development Update Feb 1995 21. http://www.who.ch/programmes/cdr/pub/newslet/update/updt-21.html

[3] Ertem, I. O., G. Kaynak, et al. (2001) Attitudes and practices of breastfeeding mothers regarding fasting in Ramadan

[4] A. Khodel , S. K., J. Nasiri, E. Taheri, M. Najafi, A. Salehifard , A. Jafari (2008). Comparison of Growth Parameters of Infants of Ramadan Fasted and Non-Fasted Mothers

[5] Prentice AM, Lamb WH, Prentice A, Coward WA (1984) The effect of water abstention on milk synthesis in lactating women

[6] Mohrbacher, N. et al. (2010) Breastfeeding Made Simple ISBN-10: 1572248610

[7] Rakicioğlu et. al. (2006) The effect of Ramadan on maternal nutrition and composition of breast milk. Pediatr Int. Jun;48(3):278-83

[8]Neville MC, Sawicki VS, Hay WW Jr. (1993) Effects of fasting, elevated plasma glucose and plasma insulin concentrations on milk secretion in women.

[9] Dr Hessa Khalfan Al Ghazal, Director of the Executive Committee for the Sharjah Baby Friendly Emirate Campaign

[10]For example, breast milk is full of antibodies and immunoglobulins that no other milk can match

[11] Wilde, C. et al. (1995) Breastfeeding: matching supply with demand in human lactation. Proc Nutr Soc1 54:401-06.

[12] Ertem, I. O., G. Kaynak, et al. (2001) Attitudes and practices of breastfeeding mothers regarding fasting in Ramadan. Child Care Health Dev. 2001 Nov;27(6):545-54.

[13] Goldman, A. (1983) Immunologic components in human milk during the second year of lactation. Acta Paediatr Scand; 72:461-62.

[14] The age at which solids are introduced are worth careful consideration as links have been made between not breastfeeding on demand, formula feeding, late solid introduction and obesity. See Kramer, M. (1981) Do breastfeeding and delayed introduction of solid foods protect against subsequent obesity? J Pediatr; 98:883-87