Nutritional composition of human milk for full-term infants

Author: Richard J Schanler, MD

Section Editor: Steven A Abrams, MD
Deputy Editor: Alison G Hoppin, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: May 2018. | This topic last updated: Feb 07, 2017.
INTRODUCTION — Human milk is recommended as the exclusive nutrient source for feeding
term infants for the first six months of life and should be continued with the addition of solid foods
after six months of age [1]. Breastfeeding for all infants is strongly supported by both
governmental and medical professional organizations because of its acknowledged benefits [1-3].
The composition of human milk is both complex, containing multiple nutrients, and remarkable for
its variability. As an example, the concentration of some nutrients may differ between women and
according to duration of lactation or time of day, whereas the concentration of other nutrients is
relatively constant [4]. The composition of human milk is ideally suited to the full-term infant. The
ability to vary the content permits nutrient composition to be adapted to meet the ongoing needs
of the infant. In addition, the lack of monotony in the diet may potentially stimulate sensory
development and permit better acceptance of new flavors and foods [5]. (See "Physiology of
lactation".)
The individual components of human milk and the ways in which they contribute to meet the
nutritional needs of full-term infants will be discussed here. Other aspects of breastfeeding and
infant nutrition are discussed in separate topic reviews:
●(See "Initiation of breastfeeding".)
●(See "Breastfeeding: Parental education and support".)
●(See "Common problems of breastfeeding and weaning".)
●(See "Infant benefits of breastfeeding".)
●(See "Maternal nutrition during lactation".)
●(See "Nutritional composition of human milk and preterm formula for the premature infant".)
COLOSTRUM — The composition of human milk fluctuates during the first two weeks of life, as
the milk changes from colostrum to relatively mature milk. Compared with mature milk, colostrum
has about double the protein content, and lower contents of carbohydrate and fat, and, therefore
lower energy content (table 1) [6].
After two weeks of age, the average composition of human milk is relatively stable, as discussed
in the sections below.
ENERGY — Although there is some variability, the energy content of mature human milk is about
20 kcal/oz (0.67 kcal/mL) (figure 1).
Average energy requirements in healthy term infants are approximately 110 kcal/kg/day at one
month of age, 95 kcal/kg/day at three months of age, and 80 kcal/kg/day between 6 and 12
months of age (figure 2).
NITROGEN — The nitrogen content of human milk is divided into protein and nonprotein
nitrogen-containing compounds.
Protein — The protein content for human milk is highest at birth and is approximately 1.8 g/dL in
milk from mothers of full-term infants (table 2) [6]. The protein concentration declines over the
next two to four weeks to a steady level of approximately 0.9 g/dL (figure 3).
For full-term infants younger than six months of age, protein needs are approximately
1.5 g/kg/day (table 3). This protein content provides about 5 to 7 percent of the caloric needs of
full-term infants and ensures an adequate protein status of the breastfed infant throughout the
first year.
Whey and casein — There are two fractions of protein defined by their solubility in acid: whey
and casein. Approximately 70 percent of the proteins in human milk are in the soluble whey
fraction and 30 percent in the insoluble casein fraction. In contrast, bovine milk protein contains
18 percent whey and 82 percent casein [7].
The high proportion of whey protein in human milk is beneficial for infants for the following
reasons:
●Compared with casein, whey is more easily digested and is associated with more rapid
gastric emptying [8].
1
 ●The whey protein fraction provides lower concentrations of potentially deleterious amino
acids, phenylalanine, tyrosine, and methionine. In high levels, these amino acids may
interfere with brain development. Infants fed human milk have lower levels of these amino
acids than infants fed bovine milk [9-11]. In addition, human milk has higher levels of cystine
(needed to synthesize the antioxidant glutathione) and taurine (needed for bile conjugation
and brain development) than bovine milk [10-12].
●The major human whey protein is alpha-lactalbumin. In bovine milk, the major whey protein
is beta-lactoglobulin, which may contribute to milk protein allergy and colic [7,13,14].
(See "Food protein-induced allergic proctocolitis of infancy" and "Milk allergy: Clinical
features and diagnosis" and "Infantile colic: Clinical features and diagnosis", section on
'Gastrointestinal'.)
●Lactoferrin, lysozyme, and secretory immunoglobulin A are specific human whey proteins
that improve host defense [15-17]. Bovine milk only has trace amounts of these proteins.
(See "Infant benefits of breastfeeding", section on 'Direct benefits'.)
Nonprotein nitrogen — In human milk, approximately 20 percent of the total nitrogen is in the
form of nonprotein nitrogen-containing compounds such as nucleotides, free amino acids, and
urea. In contrast, formula has <5 percent nonprotein nitrogen [7,18]. There is debate as to how
much these nonprotein nitrogen-containing compounds contribute to nitrogen utilization [19,20].
The rate of absorption of nonprotein nitrogen, determined by stable isotope methods, has been
estimated at 13 to 43 percent [19,20].
Nucleotides — Nucleotides represent 2 to 5 percent of the nonprotein nitrogen in human milk
and are lacking in bovine milk [21]. Nucleotides are important for gastrointestinal, immune, and
metabolic functions [21-24]. As an example, nucleotides are important for the normal
development, maturation, and repair of the gastrointestinal tract [21]. In addition, the growth of
nonpathogenic bifidobacteria in stool is enhanced by exogenous nucleotides [21]. Although
nucleotides can be synthesized endogenously, the rapid growth of infants creates a demand for
nucleotides that exceeds their endogenous supply [21].
LIPID — Lipid (fat) represents approximately 50 percent of the calories in human milk and is the
major energy source. The fat requirement of a healthy term infant, using data from breastmilk
composition, is approximately 31 g/dayfor the first six months of life (table 3) [25].
Of the macronutrients in human milk, lipid is the most variable in concentration, and this variation
is largely responsible for the variation in energy content [26]. The milk lipid content rises
throughout lactation [27], varies over the course of one day, increases within feeds, and varies
from mother to mother [4]. In particular, the lipid content of hindmilk (milk at end of expression)
may be 1.5 to 3 times more than that of foremilk (milk at beginning of expression), contributing 55
versus 42 percent of calories, respectively [28]. The total lipid content of human milk is not
affected by maternal diet, although it may be correlated directly with maternal body fat stores
[29,30]. Despite the variability among women, human milk lipid content is adequate for the
nutritional needs of the infant throughout lactation.
The lipid and energy contents of human milk increase during lactation, as outlined in the table
(table 2) [6]. This was illustrated in a study that compared human milk samples of mothers who
had breastfed for >1 year with those from mothers who had breastfed for two to six months [27].
Milk from mothers who had lactated longer provided more energy content (880 kcal/L versus
741 kcal/L, respectively) and had more fat content estimated by creamatocrit measurement (10.7
versus 7.4 percent). (Creamatocrit is determined by centrifugation of 75 microL milk samples
within glass capillary tubes. The measurement of fat is the percentage of fat to the total length of
the milk.)
Human milk facilitates lipid digestion and absorption by its organization of lipid into milk fat
globule triglycerides [31]. These globules are digested by bile salt-stimulated gastric lipase [32-
34]. Human milk is unique in its content of very long-chain fatty acids such as arachidonic acid
and docosahexaenoic acid, derivatives of the essential fatty acids, linoleic and linolenic acids.
Arachidonic and docosahexaenoic acids have been associated with improved cognition, growth,
and vision [35]. (See "Infant benefits of breastfeeding", section on 'Neurodevelopmental
outcome'.)
Fatty acids in human milk are distributed on the triglyceride molecule and consist of a high
proportion of long-chain fatty acids: palmitic, oleic, and the essential fatty acids, linoleic, and
linolenic. The triglyceride structure is designed for enhanced lipid absorption with esterification of
2
palmitic acid, the major fatty acid. This permits lipase to hydrolyze palmitic acid into two
monoglycerides, which are better absorbed than the free palmitic acid. In addition to enhanced
lipid absorption, mineral absorption is improved since free palmitic acid is not available to bind
minerals. The enhanced absorption of lipid and minerals from human milk is diminished if human
milk is pasteurized, because lipase is heat labile [36].
To match the overall lipid absorption from human milk, formula has a greater quantity of passively
absorbed medium chain-length fatty acids (MCFA) than human milk. This supplementation of
MCFA decreases the overall content of long-chain fatty acids in formula compared with human
milk.
CARBOHYDRATE — Human milk carbohydrate is comprised principally of lactose, with a small
proportion consisting of oligosaccharides. Studies in term infants demonstrate unabsorbed
lactose in the feces of breastfed infants, which is assumed to be a normal consequence of
breastfeeding [37,38]. A softer stool consistency, nonpathogenic bacterial fecal flora, and
improved absorption of minerals have been attributed to the lactose in human milk [39].
Oligosaccharides, found in carbohydrate polymers and glycoproteins, are important in the host
defense of the infant as their structures mimic specific bacterial antigen receptors. (See "Infant
benefits of breastfeeding", section on 'Anti-microbial components'.)
MINERAL AND TRACE ELEMENTS — The concentrations of calcium and phosphorus in human
milk are relatively constant through lactation (table 2), but are significantly lower than in formula.
Despite lower mineral concentration and intake, bone mineral accretion and status of breastfed
infants is similar to that of infants fed formula due to enhanced absorption (bioavailability) during
the first year of life [40,41]. In human milk, minerals are bound to digestible proteins and are also
present in complexed and ionized states, making them more readily bioavailable than in bovine
milk [42]. In one study, follow-up at eight years of age showed that children who were breastfed
compared with those not breastfed had significantly greater bone mass, and the effect was
greater in those who had breastfed for >3 months [43].
Although concentrations of iron, zinc, and copper decline during lactation, the needs for these
nutrients are usually adequately met through the first six months of life (table 3) [44,45].
Beyond six months of age, iron and other micronutrient-containing complementary foods should
be introduced to prevent deficiencies in full-term infants [46]. (See "Iron deficiency in infants and
children <12 years: Screening, prevention, clinical manifestations, and diagnosis".)
VITAMINS — Maternal vitamin status affects the content of vitamins in human milk. For example,
maternal vitamin deficiency can result in low vitamin concentrations in breast milk, which increase
in response to maternal dietary supplementation.
Potential vitamin deficiencies in breastfed infants include:
●Mothers who are on a vegan diet may be deficient in the water-soluble vitamin B12,
resulting in low breast milk levels. These mothers should receive vitamin B12
supplementation or should eat foods fortified with vitamin B12. Commonly used B12-fortified
foods include certain brands of nutritional yeasts, most ready-to-eat cereals, many meat
analogs, and some milk alternatives.
●Vitamin K deficiency is common in the newborn infant. This is due to the low vitamin K
content of breast milk, inadequate production of vitamin K by an immature liver, absence of
the bacterial flora that produce vitamin K, and poor placental transfer of vitamin K. In
breastfed infants, the plasma concentrations of all vitamin K dependent factors are about 20
percent of the adult values. Therefore, prophylactic administration of vitamin K1 oxide
(phytonadione, 1 mg intramuscularly) is given to newborns shortly after birth to prevent
vitamin K hemorrhagic disease of the newborn. (See "Overview of vitamin K", section on
'Vitamin K deficient bleeding in newborns and young infants' and "Overview of the routine
management of the healthy newborn infant", section on 'Vitamin K'.)
●The content of vitamin D in human milk is low. Vitamin D supplementation should be
provided to exclusively breastfed infants and non-breastfed infants who do not ingest an
adequate amount of vitamin D-fortified milk daily. (See "Vitamin D insufficiency and
deficiency in children and adolescents", section on 'Vitamin D supplementation for infants'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from
selected countries and regions around the world are provided separately. (See "Society guideline
links: Breastfeeding and infant nutrition".)

3
 INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials,
"The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written at
the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Deciding to breastfeed (Beyond the
Basics)" and "Patient education: Common breastfeeding problems (Beyond the
Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)" and "Patient
education: Maternal health and nutrition during breastfeeding (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Human milk is recommended as the exclusive nutrient source for infants during the first six
months of life. Human milk should be continued along with complementary foods through 12
months of age, and subsequent breastfeeding can continue depending on the mutual
agreement between mother and infant. (See "Infant benefits of breastfeeding".)
●Lipid (fat) represents approximately 50 percent of the calories in human milk and is the
major energy source. The milk lipid content rises throughout lactation (table 2), varies over
the course of one day, increases within feeds, and varies from mother to mother.
(See 'Lipid' above.)
●Human milk provides the necessary nutrients for the full-term infant, including energy,
protein, lipid, carbohydrate, vitamin, mineral, and trace elements (figure 2 and table 3), with
the following exceptions:
•Prophylactic vitamin K supplementation is given to newborns shortly after birth to
prevent vitamin K deficient bleeding. (See 'Vitamins' above.)
•Vitamin D supplementation is recommended for all infants, at a dose of 400
international units/day. (See 'Vitamins' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012;
129:e827.
2. Department of Health and Human Services, Office on Women's Health. Breastfeeding:
HHS Blueprint for Action on Breastfeeding. US Department of Health and Human Services,
Washington, DC 2000.
3. American College of Obstetricians and Gynecologists. Breastfeeding: maternal and infant
aspects. ACOG Educational Bulletin 258, American College of Obstetricians and Gynecologists,
Washington DC, 2000.
4. Neville MC, Keller RP, Seacat J, et al. Studies on human lactation. I. Within-feed and
between-breast variation in selected components of human milk. Am J Clin Nutr 1984; 40:635.
5. Mennella JA. Mother's milk: a medium for early flavor experiences. J Hum Lact 1995;
11:39.
6. Gidrewicz DA, Fenton TR. A systematic review and meta-analysis of the nutrient content
of preterm and term breast milk. BMC Pediatr 2014; 14:216.
7. Hambraeus L. Proprietary milk versus human breast milk in infant feeding. A critical
appraisal from the nutritional point of view. Pediatr Clin North Am 1977; 24:17.
8. Billeaud C, Guillet J, Sandler B. Gastric emptying in infants with or without gastro-
oesophageal reflux according to the type of milk. Eur J Clin Nutr 1990; 44:577.
9. Rassin DK, Gaull GE, Räihä NC, Heinonen K. Milk protein quantity and quality in low-
birth-weight infants. IV. Effects on tyrosine and phenylalanine in plasma and urine. J Pediatr 1977;
90:356.
10. Gaull GE, Rassin DK, Räihä NC, Heinonen K. Milk protein quantity and quality in low-
birth-weight infants. III. Effects on sulfur amino acids in plasma and urine. J Pediatr 1977; 90:348.
4
11. Järvenpää AL, Rassin DK, Räihä NC, Gaull GE. Milk protein quantity and quality in the
term infant. II. Effects on acidic and neutral amino acids. Pediatrics 1982; 70:221.
12. Järvenpää AL, Räihä NC, Rassin DK, Gaull GE. Feeding the low-birth-weight infant: I.
Taurine and cholesterol supplementation of formula does not affect growth and metabolism.
Pediatrics 1983; 71:171.
13. Jakobsson I, Lindberg T, Benediktsson B, Hansson BG. Dietary bovine beta-lactoglobulin
is transferred to human milk. Acta Paediatr Scand 1985; 74:342.
14. Savilahti E, Kuitunen M. Allergenicity of cow milk proteins. J Pediatr 1992; 121:S12.
15. Goldman AS, Chheda S, Keeney SE, et al. Immunologic protection of the premature
newborn by human milk. Semin Perinatol 1994; 18:495.
16. Lönnerdal B. Biochemistry and physiological function of human milk proteins. Am J Clin
Nutr 1985; 42:1299.
17. Hanson LA, Ahlstedt S, Andersson B, et al. Protective factors in milk and the development
of the immune system. Pediatrics 1985; 75:172.
18. Carlson SE. Human milk nonprotein nitrogen: occurrence and possible functions. In:
Advances In Pediatrics, Barness LA (Ed), Year Book Medical Publishers, Inc., Chicago 1985.
p.43.
19. Heine W, Tiess M, Wutzke KD. 15N tracer investigations of the physiological availability of
urea nitrogen in mother's milk. Acta Paediatr Scand 1986; 75:439.
20. Fomon SJ, Bier DM, Matthews DE, et al. Bioavailability of dietary urea nitrogen in the
breast-fed infant. J Pediatr 1988; 113:515.
21. Uauy R, Quan R, Gil A. Role of nucleotides in intestinal development and repair:
implications for infant nutrition. J Nutr 1994; 124:1436S.
22. Carver JD, Walker WA. The role of nucleotides in human nutrition. Nutr Biochem 1995;
6:58.
23. Schaller JP, Kuchan MJ, Thomas DL, et al. Effect of dietary ribonucleotides on infant
immune status. Part 1: Humoral responses. Pediatr Res 2004; 56:883.
24. Buck RH, Thomas DL, Winship TR, et al. Effect of dietary ribonucleotides on infant
immune status. Part 2: Immune cell development. Pediatr Res 2004; 56:891.
25. American Academy of Pediatrics. Pediatric Nutrition Handbook, 7, Kleinman RE, Greer FR
(Eds), American Academy of Pediatrics, Elk Grove Village 2014.
26. Butte NF, Garza C, Smith EO. Variability of macronutrient concentrations in human milk.
Eur J Clin Nutr 1988; 42:345.
27. Mandel D, Lubetzky R, Dollberg S, et al. Fat and energy contents of expressed human
breast milk in prolonged lactation. Pediatrics 2005; 116:e432.
28. Valentine CJ, Hurst NM, Schanler RJ. Hindmilk improves weight gain in low-birth-weight
infants fed human milk. J Pediatr Gastroenterol Nutr 1994; 18:474.
29. Nommsen LA, Lovelady CA, Heinig MJ, et al. Determinants of energy, protein, lipid, and
lactose concentrations in human milk during the first 12 mo of lactation: the DARLING Study. Am
J Clin Nutr 1991; 53:457.
30. Butte NF, Garza C, Stuff JE, et al. Effect of maternal diet and body composition on
lactational performance. Am J Clin Nutr 1984; 39:296.
31. Jensen RG. The lipids in human milk. Prog Lipid Res 1996; 35:53.
32. Hernell O, Bläckberg L. Human milk bile salt-stimulated lipase: functional and molecular
aspects. J Pediatr 1994; 125:S56.
33. Jensen RG, Jensen GL. Specialty lipids for infant nutrition. I. Milks and formulas. J Pediatr
Gastroenterol Nutr 1992; 15:232.
34. Sauerwald TU, Demmelmair H, Koletzko B. Polyunsaturated fatty acid supply with human
milk. Lipids 2001; 36:991.
35. Uauy R, Hoffman DR, Peirano P, et al. Essential fatty acids in visual and brain
development. Lipids 2001; 36:885.
36. Jensen RG, Hagerty MM, McMahon KE. Lipids of human milk and infant formulas: a
review. Am J Clin Nutr 1978; 31:990.

5
37. Whyte RK, Homer R, Pennock CA. Faecal excretion of oligosaccharides and other
carbohydrates in normal neonates. Arch Dis Child 1978; 53:913.
38. MacLean WC Jr, Fink BB. Lactose malabsorption by premature infants: magnitude and
clinical significance. J Pediatr 1980; 97:383.
39. Ziegler EE, Fomon SJ. Lactose enhances mineral absorption in infancy. J Pediatr
Gastroenterol Nutr 1983; 2:288.
40. Venkataraman PS, Luhar H, Neylan MJ. Bone mineral metabolism in full-term infants fed
human milk, cow milk-based, and soy-based formulas. Am J Dis Child 1992; 146:1302.
41. Greer FR, Searcy JE, Levin RS, et al. Bone mineral content and serum 25-hydroxyvitamin
D concentrations in breast-fed infants with and without supplemental vitamin D: one-year follow-
up. J Pediatr 1982; 100:919.
42. Neville MC, Watters CD. Secretion of calcium into milk: review. J Dairy Sci 1983; 66:371.
43. Jones G, Riley M, Dwyer T. Breastfeeding in early life and bone mass in prepubertal
children: a longitudinal study. Osteoporos Int 2000; 11:146.
44. Casey CE, Hambidge KM, Neville MC. Studies in human lactation: zinc, copper,
manganese and chromium in human milk in the first month of lactation. Am J Clin Nutr 1985;
41:1193.
45. Dallman PR, Siimes MA, Stekel A. Iron deficiency in infancy and childhood. Am J Clin Nutr
1980; 33:86.
46. Lönnerdal B, Hernell O. Iron, zinc, copper and selenium status of breast-fed infants and
infants fed trace element fortified milk-based infant formula. Acta Paediatr 1994; 83:367.