Effect of Ramadan Fasting on Breast Milk

Abstract

Introduction:

Breast milk is an excellent biofluid that ensures optimal growth, development, and strong immunity of the baby. Breast milk content may alter depending on duration and time of breastfeeding, the infant's age, and maternal health status. There are few studies in the literature investigating the effect of religious fasting on breast milk composition.

Method:

The study included 21 fasting and 27 nonfasting mothers who exclusively breastfed their babies in 2021 Ramadan month. The energy, carbohydrate, protein, and lipid levels of the collected breast milk samples and the macro- and micronutrient contents of the mothers' diets and the weight gain of the infants during the study were evaluated.

Results:

The mothers' ages, education levels, and weights at birth and at the time of sampling were similar. There was no significant difference between the energy, carbohydrate, protein, and lipid composition of breast milk in fasting and nonfasting mothers. Although daily energy, protein, carbohydrate, fiber, and vitamin intakes between two groups were similar, mean daily intake of lipid, sodium, chloride, iodine, and omega-3 fatty acids was determined significantly higher in study group. Also, there was no difference in the weight gain of babies during the month of Ramadan.

Conclusion:

Religious fasting of mothers does not affect the energy and macronutrient content of breast milk. In addition, fasting does not seem to affect the weight of mothers and babies.

Introduction

Breast milk is a unique nutrient that protects the baby and mother from many acute and chronic diseases and ensures the baby's optimal growth and development.¹ The World Health Organization recommends exclusive breastfeeding for the first 6 months and continued breastfeeding with appropriate complementary feeding from the age of 6 months for up to 2 years and beyond.²

Breast milk composition changes dynamically within a feeding, with time of day, over lactation, and between mothers and populations. The most affective factors are infant sex and infective status by genetic and environmental factors, as well as by maternal lifestyle, including dietary habit.^3,4 Also, as stated in previous studies, the composition of breast milk is partially dependent on the mother's diet.^5,6 Maternal nutrition affects the composition of milk in three different ways: changes in current dietary intake, body stores, and nutrient use, which is affected by hormonal changes that are an important feature of lactation.⁷ However, mild or moderate variations in maternal diet and energy balance generally do not affect milk production.⁸

In a systematic review, some micronutrients such as fatty acids, fat-soluble vitamins, vitamin B1, and C in the mother's diet were associated with content in breast milk. Maternal vitamin and mineral supplementation also affects the levels of fat-soluble vitamins, B1, B2, and C in breast milk.^2,5,9 However, a recently published review reported insufficient or no evidence to assess the association between dietary patterns and several other outcome, including breast milk amount and composition of total protein, water-soluble vitamins (B, C, and choline), fat-soluble vitamins (A, D, E, and K), minerals (iodine and selenium), breast milk oligosaccharides and bioactive proteins (alpha-lactalbumin, lactoferrin, casein, alpha-1 antitrypsin, osteopontin, secretory immunoglobulin A, and lysozyme).¹⁰

Ramadan covers a 1-month period during which healthy adult Muslims are prohibited from consuming food and beverages, including water, from sunrise to sunset. The food items and amounts intake during the fasting period, which varies between 11 and 18 hours depending on the regions, may change.¹¹ The studies concluded that healthy well-nourished mothers produced normal amounts of milk and would not experience a reduction in milk supply, even with a reduction in short-term calorie intake during short-term fasting. But some mothers find that fasting leads to early weaning and prolonged lack of hydration reduces milk supply.¹²

Although breastfeeding women are religiously exempt from fasting during Ramadan, it is known that many women prefer fasting.^13,14 The aim of our study is to investigate the effect of Ramadan fasting on breast milk content.

Materials and Methods

Subject

The sample size of the prospective observational study conducted in Medipol Çamlıca hospital in April 2021 during Ramadan was determined as a 5% margin of error and 80% power were determined with a standard effect size of 0.87 to 21. The records of mothers who gave birth at the hospital were examined and 990 mothers between the ages of 18 and 39 years whose babies will be between 1 and 6 months were called before a week before Ramadan. Whereas 25 mothers who agreed to participate in the study and fasted were included in the study group, 27 mothers who did not fast consisted the control group. The criteria for inclusion in the study were that the baby was exclusively breastfed and did not have a chronic disease or anomaly, the mother did not use alcohol or smoke or drugs, did not have a chronic disease and was willing to participate in the study.

Study design and sample collection

On fasting days, mothers could not eat or drink anything, including water, between 04:24, the time of dawn, and 20:03, the time of evening prayer (sunset). Each mother were asked to express 5 mL of breast milk manually between the 15th and 18th days of Ramadan, at 10:00 am after breastfeeding. Ten samples of milk were collected under the supervision of a doctor at the mothers' homes and immediately frozen at −18°C. They were then transported to the laboratory using a cold box. The samples taken from the remaining mothers in the hospital were delivered to the laboratory by the lactation consultant nurse. The samples were stored in sterile polypropylene tubes and kept on ice and transported to the laboratory in a cool box and each milk samples specimens were also kept frozen at −20°C. All samples were transported to the laboratory with cold chain conditions.

All mothers were asked to record their food consumption during the 24 hours before collecting the milk sample.

The mothers' age, education level, prepregnancy weight and weight at labor were asked to the mother. Actual weight and height were measured by the same researcher in the clinic with a digital adult weight and height scale (ADE^©). Body mass index (BMI) was calculated with the “kg/height²” formula.

The age, gender, week of gestation, mode of delivery, birth weight, height, and head circumference at birth of the infants were recorded from hospital follow-up files. The baby's weight at the beginning and end of Ramadan was measured by a same researcher with a digital pediatric scale (ADE) in accordance with the standards.

Analytical methods

Carbohydrate, protein, and fat and energy content of the samples were measured in the laboratory of Marmara University Department of Nutrition and Dietetics by the International Standards Organization 9622: 1999 approved Miris^® HMA™ device by the same investigator. With different filters for milk components, the device calculates the composition of each macronutrient in grams per 100 mL, using four different wavebands for fat, protein, and lactose determination. Measurable ranges of nutrients:

Fat: 0.6–5.9 g/100 mL

Protein: 0.8–3 g/100 mL

Carbohydrate: 4–8 g/100 mL.

All the examples were worked on by the same person at the same time. The samples were studied twice for the reliability of the results.

Analysis of mothers' diet

The 24-hour food consumption of the mothers on the day before taking the milk sample was analyzed using the BeBis 9 (Nutritional Composition System) program, and their daily nutrient requirements was compared with the daily nutrient requirement values for nursing mothers in the Turkish Nutrition Guide (TÜBER 2015).¹⁵

Written informed consent was obtained from the mothers who agreed to participate in the study.

Ethics committee approval

Our study was approved by the ethics committee of Medipol University Faculty of Medicine (No. 417/2021).

Statistical analysis

In the descriptive statistics of the data, mean, standard deviation, median minimum, maximum, frequency, and ratio values were used. The distribution of variables was measured with the Kolmogorov–Smirnov test. Independent sample t test, Kruskal–Wallis, and Mann–Whitney U test were used in the analysis of quantitative independent data. Chi-square test was used in the analysis of qualitative independent data. Analyses were performed with the SPSS 28.0 program.

Results

Although a total of 52 mother–infant pairs, 25 fasting and 27 not, were included, the study was completed with 21 mothers because the sample of 4 mothers in the study group was insufficient. There was no significant difference between the groups in terms of maternal age, education level, prepregnancy, birth and actual weight, BMI and education levels, gestational week of the babies, type of delivery, age, gender, birth, and actual anthropometric measurements (p > 0.05) (Table 1).

Table 1.

Demographic Characteristics of Mothers and Babies

	Fasting		Nonfasting		p
	Mean ± std	Median	Mean ± std	Median	p
Mother's age (years)	29.0 ± 4.7	29.0	29.1 ± 4.2	28.0	0.843^a
Weight—give birth	76.9 ± 8.7	76.0	78.3 ± 8.4	78.0	0.573^b
Weight (kg)	66.5 ± 10.1	65.0	68.2 ± 10.1	69.0	0.571^b
BMI—give birth	29.1 ± 3.3	29.7	29.7 ± 3.5	30.1	0.529^b
BMI	25.2 ± 3.7	25.7	25.9 ± 3.8	26.2	0.531^b

	n	%	n	%
Education
Primary school	1	4.8%	0	0.0%	0.790^c
Middle school	2	9.5%	2	7.4%
High school	4	19.0%	8	29.6%
University	13	61.9%	2	7.4%
Master's degree	1	4.8%	1	3.7%
PhD	0	0.0%	2	7.4%

	Mean ± std	Median	Mean ± std	Median	p
Age of child (days)	121.6 ± 39.4	120.0	128.1 ± 49.8	126.0	0.629^b
Birthweight (g)	3,490.8 ± 460.9	3,510.0	3,276.1 ± 460.7	3,380.0	0.142^a
Gestation week	38.1 ± 3.3	38.5	38.3 ± 1.4	38.1	0.581^a
Weight (g)	6,926.2 ± 1,216.0	7,000.0	7,042.5 ± 1,380.7	7,450.0	0.762^b
Height (cm)	65.0 ± 5.0	65.5	64.0 ± 5.2	63.0	0.531^b
Head circumference (cm)	41.6 ± 1.2	42.0	41.5 ± 1.7	41.5	0.939^a

	n	%	n	%
Gender
Girl	9	42.9%	18	66.7%	0.099^c
Boy	12	57.1%	9	33.3%	0.099^c
Birth type
Spontaneous vaginal	6	28.6%	10	37.0%	0.537^c
Cesarean section	15	71.4%	17	63.0%	0.537^c

Mann–Whitney U test.

Independent sample t test.

Ki-kare test.

BMI, body mass index.

There was no significant difference between the energy, carbohydrate, protein, and fat levels of breast milk in both groups (Table 2).

Table 2.

Macronutrient Contents of Breast Milk

	Study group		Control group		p
	Mean ± std	Median	Mean ± std	Median	p
Fat	2.9 ± 1.5	3.0	2.7 ± 1.2	2.7	0.638^a
Protein	0.7 ± 0.2	0.7	0.9 ± 0.5	0.8	0.292^b
Carbohydrate	7.2 ± 0.2	7.2	6.9 ± 1.1	7.2	0.607^b
Energy	59.8 ± 13.4	61.0	58.1 ± 10.1	58.0	0.637^a

Independent sample t test.

Mann–Whitney U test.

Although the daily energy, protein, carbohydrate, fiber, and vitamin intake levels were similar, the daily fat intake of the mothers in the study group was found to be significantly higher (p < 0.05) (Tables 3 and 4).

Table 3.

Daily Macronutrient Intake of Mothers

	Study group		Control group		p
	Mean ± std	Median	Mean ± std	Median	p
Energy (kcal)	1,544.8 ± 419.1	1,514.0	1,375.3 ± 681.4	1,127.4	0.294^a
Protein (g)	64.0 ± 21.9	57.5	54.6 ± 22.6	51.2	0.153^a
Protein %	16.7 ± 3.7	16.0	17.2 ± 5.2	16.0	0.703^a
Fat (g)	74.0 ± 20.0	68.3	58.1 ± 18.8	54.9	0.008 ^a,*
Fat %	43.0 ± 7.6	43.0	40.8 ± 10.6	41.0	0.411^a
CHO (g)	155.2 ± 54.9	150.7	155.0 ± 139.9	114.6	0.098^b
CHO %	40.3 ± 7.8	42.0	42.1 ± 12.5	39.0	0.525^a

Statistically significant p-value is p < 0.05.

Independent sample t test.

Mann–Whitney U test.

Table 4.

Daily Micronutrient Intake of the Mothers

	Study group		Control group		p
	Mean ± std	Median	Mean ± std	Median	p
Fiber (g)	14.6 ± 6.4	14.1	14.4 ± 14.4	10.9	0.132^a
Vitamin A (μg)	1,082.7 ± 1,096.5	746.2	896.5 ± 592.0	752.0	0.486^a
Vitamin D (μg)	3.41 ± 2.38	2.63	3.67 ± 3.21	3.24	0.771^a
Vitamin E (eq.) (mg)	10.3 ± 6.8	7.2	9.2 ± 6.0	6.7	0.655^a
Vitamin K (μg)	117.3 ± 106.2	83.1	77.2 ± 57.8	57.4	0.216^a
Thiamin (mg)	0.68 ± 0.21	0.68	0.58 ± 0.20	0.53	0.109^a
Riboflavin (mg)	1.17 ± 0.40	1.06	1.14 ± 0.98	0.98	0.143^a
Niacin (mg)	11.6 ± 5.4	10.0	10.9 ± 5.7	9.7	0.603^a
Niacin eq. (mg)	23.5 ± 9.6	19.4	21.7 ± 9.7	19.0	0.461^a
Vitamin B5 (mg)	4.02 ± 1.03	3.93	4.05 ± 2.16	3.59	0.436^a
Vitamin B6 (mg)	0.93 ± 0.30	0.84	0.88 ± 0.38	0.83	0.655^b
Biotin (μg)	37.6 ± 11.3	40.8	41.3 ± 29.2	37.6	0.779^a
Folate (μg)	240.5 ± 89.9	244.4	231.6 ± 174.4	198.1	0.224^a
Vitamin B12 (μg)	4.30 ± 2.03	4.33	6.96 ± 15.66	3.23	0.324^a
Vitamin C (mg)	80.0 ± 60.0	63.6	60.5 ± 37.0	53.7	0.275^a
Sodium (mg)	2,247.9 ± 965.3	2,084.2	1,410.5 ± 771.9	1,191.2	0.002 ^b
Potassium (mg)	1,969.1 ± 724.8	1,797.4	1,907.6 ± 1,157.3	1,692.5	0.355^a
Calcium (mg)	591.9 ± 269.9	629.4	465.9 ± 195.5	517.4	0.078^b
Magnesium (mg)	207.3 ± 61.3	199.9	180.9 ± 70.3	185.1	0.172^b
Phosphorus (mg)	928.2 ± 276.1	924.0	803.0 ± 273.2	725.9	0.124^b
Sulfur (mg)	673.6 ± 249.7	611.2	566.5 ± 275.0	512.4	0.132^a
Chlorine (mg)	2,781.4 ± 1,318.8	2,510.2	1,498.1 ± 1,110.5	1,313.4	0.001 ^b
Iron (mg)	8.49 ± 2.63	7.92	8.53 ± 4.47	7.29	0.540^a
Zinc (mg)	9.27 ± 3.22	8.62	7.46 ± 2.93	6.54	0.050^b
Copper (mg)	1.16 ± 0.45	1.08	1.31 ± 1.01	0.90	0.603^a
Manganese (mg)	3.80 ± 4.41	2.64	4.51 ± 5.46	2.77	0.442^a
Fluorine (μg)	503.3 ± 242.5	480.0	502.8 ± 268.6	406.9	0.843^a
Iodine (μg)	91.4 ± 48.3	85.3	52.1 ± 40.7	40.6	0.001 ^a
Omega 3 (g)	1.51 ± 0.85	1.22	1.05 ± 0.96	0.60	0.007 ^a
Omega 6 (g)	9.09 ± 5.89	7.87	6.53 ± 4.50	4.42	0.088^a

Statistically significant values are indicated in bold ital, where p < 0.05.

Mann–Whitney U test.

Independent sample t test.

In addition, daily intake of sodium, chlorine, iodine, and omega-3 was significantly higher in the study group (Table 4).

The weight gains of the all babies in Ramadan were similar (Table 5).

Table 5.

Weight Gain of the Babies

	Study group		Control group		p
	Mean ± std	Median	Mean ± std	Median	p
Weight (kg)
At the beginning of Ramadan	6,926.2 ± 1,216.0	7,000	7,042.5 ± 1,380.7	7,450	0.632^a
At the end of Ramadan	7,816.7 ± 1,141.9	8,090	7,832.8 ± 1,394.5	8,200	0.819^a
Weight gain	890.5 ± 164.2	890	790.4 ± 139.0	780	0.026 ^a,*

Statistically significant p-value is p < 0.05.

Mann–Whitney U test.

Discussion

Although breastfeeding women are exempt from fasting, it is known that a large number of lactating women prefer fasting during these periods. In our study, Ramadan fasting did not affect energy and macronutrients of breast milk was shown. Also, the food intake of the two groups was similar, except that the mothers in the study group had a high intake of fat, sodium, chlorine, iodine, and omega-3.

Although the effect of fasting on breastfeeding is a remarkable issue, there are limited studies on this subject. In a study investigating the breast milk composition of 26 breastfeeding mothers during and after Ramadan in the United Arab Emirates, Bener et al. reported that there was no significant change in the total fat, protein, lactose, triglycerides, and cholesterol content of breast milk, and that Ramadan fasting did not affect the breast milk content.¹¹ In Rakicioglu's study that investigating the effect of fasting on maternal nutrition and the composition of breast milk, some micronutrient levels in breast milk decreased, whereas lactose, fat, and protein levels did not change were determined.¹⁶ Allegaert et al. showed that the effect of chronic repetitive fasting during Ramadan on breast milk was moderate, but clinically insignificant.¹⁷ In our study was found that fasting did not affect the macronutrient content of breast milk.

In the study conducted by Adlouni et al. food intake patterns were investigated during Ramadan was found that an increase in carbohydrate and protein intake during Ramadan.¹⁸ Gökdemir et al. also showed that mothers tend to consume more food during Ramadan.¹⁹ However, Rakıcıoğlu et al. reported that fasting causes the mother's daily food intake to be insufficient.¹⁶ In contrast, a study from Bangladesh reported that both fasting and nonfasting Muslim women during Ramadan improved their nutritional quality, and lactating mothers tended to have more varied diets.²⁰ In our study was found that the daily fat, sodium, chlorine, iodine, and omega-3 intakes of fasting mothers were higher than the control group.

A systematic review found that maternal dietary intake, particularly fatty acids, and fat-soluble vitamins, vitamin B1 and C, was associated with micronutrient content of the breast milk.¹⁸ Hachey et al. reported that the nutritional habits of lactating mothers affect the composition of milk. In this study, the total fat concentration of breast milk was 2.5% in low-fat diet and 3.3% in high-fat diet.²¹ In our study, fat consumption was significantly higher in the study group, but the lipid content of milk was found to be similar in the two groups.

Ramadan fasting by breastfeeding mothers did not adversely affect the growth of exclusively breastfed infants in short term.²² In our study, difference between the two groups in terms of maternal BMI and infant anthropometric measurements was not significant.

When mothers who fast and do not fast during Ramadan are compared, lower education level of fasting mothers was reported.¹³ There was no significant difference between maternal education levels.

As a conclusion, fasting of mothers whose diet does not change except for fat does not affect the energy and macronutrient content of breast milk. In addition, fasting does not seem to affect the weight of mothers and babies.

Footnotes

Authors' Contributions

Design and coordination of the project, clinical evaluation collection and analysis of patient data, writing and revising the article draft, preparation of the article draft, and approval of its final form by M.B. and N.K. Performing laboratory tests and interpreting the results, and final reading by Ş.A. and S.K. Writing and revising the article draft by Ö.B. All authors have agreed upon the publication of the final version of the article and are accountable for its content.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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