Elimination, Detox, and the Breastfeeding Mom
Elimination diets can be utilized for many reasons. Often during breastfeeding they are used to help with infant food allergies that can be manifesting in colic, constipation, reflux, or atopic dermatitis (1). There are also times when mothers need to undertake an elimination diet for their health. In both instances it is vital for the mother to ensure she is getting the adequate calories and nutrients needed to support herself and her infant during breastfeeding. This can be done by continuing to consume nutrient dense fruits, vegetables, quality proteins, and adequate fats of all varieties including small amounts of saturated, monounsaturated and polyunsaturated fats. Whole unprocessed foods are rich in micronutrients and according to Nocerino et al, (2015) micronutrient content in breastmilk is dependent on maternal diet.
One major question many people have is if following an elimination diet actually helps improve conditions of concern. As with many health and nutrition related topics the answer is not clear cut. In much of the literature found on the subject of elimination diets and breastfeeding the evidence was not always conclusive. Though often women do notice improvements in their infants health or symptoms when an elimination diet is used. If the jury is still out on elimination diets where do we start when we feel our child is reacting to what we are eating? Whether it be colic, reflux, constipation or atopic dermatitis (AD) many providers will tell you to eliminate the top 6 or 8 offenders, these include eggs, dairy, soy, peanuts, tree nuts, fish, shellfish and wheat (2). The proteins in these foods account for 90% of the allergies related to food in the United states according to the Food Allergy Research and Education organization.
Let’s take a minute and break down the most common reactions:
Colic is common in almost all infants during period of growth. True colic is classified as irritability, crying or fussiness that persists for 3 hours or more in a day, on more than 3 days per week, for more than 3 weeks (3). In infants with colic it has been noted that cow’s milk is often a common factor(1,2,5). In the breastfed infant intact proteins can be passed through the mother's milk to the infant causing an immunologic response. The response was not limited to only cow’s milk but other potential allergens as well including wheat, peanuts, and fish. One study showed that in mothers’ with infants 6 weeks of age or less there was improvement in infant crying and colic periods with the use of a low allergen maternal diet (3).
Reflux disease is often linked with persistent crying and feeding refusal. The cause of this is due to the passive flow of stomach contents into the esophagus, and can be related to low tone of the sphincter found at the bottom of the esophagus or top of stomach (3). Reflux is different from vomiting in infants there will often be signs of mucosal injury, respiratory complications for potential aspiration of contents into the lungs, or failure to thrive due to lack of nutrient absorption from the mother’s milk. Cow’s milk proteins have been linked with reflux disease in some infants and as with many other potential allergens there seem to be associated delayed onset reactions. Removing the allergen from the mother’s diet does seem to help with symptom management (3).
Constipation is yet another disorder associated with the common food allergens. This in part could be due to the potential altered gut bacteria in the infant and exposure to the offending foods proteins via breast milk. When an infant is exposed and reacts to allergens early on there will be an imbalance of flora in the gut leading to higher levels of e. Coli and other bacteria that can increase gas production and affect bowel habits in the infant (1). Again much of the literature suggests that cow’s milk allergy might be our greatest offender, but saw greater improvement in the infant health with a full hypoallergenic elimination diet of the mother.
Atopic disease is often seen in infants as a delayed response to an offending allergen. Typically the elimination diet is recommended in mothers who have a family history of atopic disease like eczema. It appears that there is conflicting research on if it will prevent the infant from ever getting AD. However, there has been improvement noted when a mother takes part in an hypoallergenic elimination diet to improve AD when it is presenting in an infant (4). Due to the fact that allergens are transferred into the breastmilk an elimination diet can improve symptoms of AD in infants and possibly prevent AD development though the research is still unclear on this as well (4)
Considering the overall health of our infant it is obvious why many women would take part in an elimination diet. If their child was not thriving, vomiting, or excessively fussy, it can cause much stress, worry or often feelings of failure as a mother. What about the times when the mother is having health issues that require an elimination diet? Are these diets safe in the long term? Has there been much research done? In regards to research there is limited if any controlled research on breastfeeding mothers participating in elimination diets for their own health. Safety issues would come into play if the mother is restricting calories, restricting potential nutrients, and not assessing her child’s health as it relates to her continued breastfeeding.
Elimination diets can be beneficial in helping control chronic pain, identifying food allergies or sensitivities, or managing autoimmune conditions which can often be exacerbated during or after pregnancy. There are many types of elimination diet the most common ones include the Six Food elimination diet, Paleo, and oligoantigenic diets (also known as the anti inflammatory diet). All of these elimination diets omit dairy, gluten or wheat containing foods, and soy. Other things that might be omitted would include all grain, all legumes, nuts, seeds, eggs, or seafood products. There is great potential for a mother to become nutrient deficient if she is not assuring her consumption of nutrient dense foods. There are plenty of ways to maintain health and adequate milk production but some key nutrients to pay close attention to would include
DHA- an essential fatty acid that is required for growth and development of the brain (5). DHA is often low in the typical Western diet due to a low consumption of fatty fish. If fish is omitted from the diet a great source of DHA would include blue green algae like Spirulina. There are other vegetarian sources of fatty acids the problem lies in the low conversion to the useful form of DHA.
Iron- this is needed for all humans and can be obtained through things like leafy green vegetables or animal protein. Grass Fed beef would be a great source of iron plus it also gets you some CLA or conjugated linoleic acid which is also a fatty acid. Often during pregnancy and in the immediate postpartum period iron can become depleted. Iron is required to help transport oxygen throughout our bodies (5).
Vitamin D - another big nutrient to keep tabs on. More and more research is coming out on the impact of vitamin D as it relates to gut health, and immune system function (Marangoni). Sadly we need to supplement with vitamin D rich foods to maintain adequate levels in our breastmilk. Food rich in vitamin D would include many of the food removed from an elimination diet like eggs, butter, high fat cheeses, and as well as fish or cod liver oil. In this case it would be beneficial for the mother to supplement with vitamin D so talking with your doctor if he is prescribing a six food elimination diet would be indicated.
Calcium - thankfully dairy is not the only way to get enough calcium in our diets. If you are allowed to consume fish products eating whole sardines would be a great source of calcium, if sardines aren’t your favorite food then eating plenty of dark leafy greens, figs, or white beans could get you closer to the the RDA recommendation.
Once nutrient needs are addressed the next big issue is when you get to reintroduce foods? It is often recommended that the body is given time to adjust to the diet change. This usually takes 21-30 days at minimum. In this time symptoms of concern whether it be in the mother or the infant would be monitored. After the complete removal period, foods should be reintroduced slowly, and one at a time, with 2-3 days between each food. It can take a few days for symptoms to appear due to the delayed immune reaction. In this time write down how the body is reacting to each food 1-3 days after the introduction of the eliminated food group. It would also be beneficial to write down the child’s reactions if any are noted. This is a great way to figure out what foods are causing the issues. It is not uncommon that some foods can be reintroduced over time.
Elimination diets can be a useful tool for many women and infants. The reality of it is that one needs to eat in a mindful way, and assure they are consuming nutrient dense foods to meet the needs of a growing infant and the mother. Whether the elimination needs are to help with the health of the mother or to improve symptoms noticed in an infant it is always wise to work with a professional who understands the needs of a breastfeeding mother. A nutritionist or dietician can help with meal plans or give guidelines to follow when eliminating foods from the diet.
Nocerino, R., Pezzella, V., Cosenza, L., Amoroso, A., De Scala, C., Amato, F., Iancono, G., & Berni Canani, R. (2015). The Controversial Role of Food Allergy in Infantile Colic: Evidence and Clinical Management. Nutrients. 7 2015-2025.
Kagalwalla, A., Shah, A., Li, B., Sentongo, T., Ritz, S., Manuel-Rubio, M.,...Nelson, S. (2011). Identification of Specific Foods Responsible for Inflammation in Children with Eosinophilic Esophagitis Successfully Treated with Empiric Elimination Diet. Gastroenterology. 53(2) 145-149
Lien, T., & Goldman, R. (2011). Breastfeeding and Maternal Diet in Atopic Dermatitis. 57 1403-1409
Heine, R. (2006). Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Current Opinion in Allergy and Clinical Immunology. 6 220-225
Marangoni, F., Cetin, I., Verduci, E., Ganzone, G., Giovannini, M., Scollo, P...Poli, A. (2016) Maternal Diet and Nutrient Requirements in Pregnancy and Breastfeeding. An Italian Consensus. 8 629-646