Journal of the American College of Nutrition, Vol. 19, No. 2, 210-219 (2000)
Published by the American College of Nutrition
Magnesium in Human Milk
José G. Dórea, PhD
Department of Nutrition, Universidade de Brasilia, 70919-970 Brasilia, BRAZIL
Address reprint requests to: José G. Dórea, PhD, Department of Nutrition, Universidade de Brasilia, 70919-970 Brasilia, BRAZIL
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ABSTRACT
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Reported concentrations for magnesium in breast milk vary over a wide range (15 to 64 mg/L) with a median value of 31 mg/L and 75% of reported mean concentrations below 35 mg/L. Constitutional variables such as adolescent motherhood, gestation length, maternal undernutrition, metabolic disorders (diabetes, galactosemia), race, stage of lactation, sampling techniques (foremilk and hindmilk), as well as environmental variables such as socio-cultural diversity, smoking habits, dietary calcium and magnesium (including supplementation), vegetarianism, calciotropic agents (immunoreactive calcitonin, vitamin D), medication (hormonal contraceptives, magnesium sulfate) are critically reviewed in relation to changes in milk magnesium concentrations. Magnesium secretion into breast milk does not seem to be affected by the studied variables.
Key words: magnesium, milk, gestation age, smoking, diabetes, diet
Key teaching points:
Reference magnesium concentrations in human milk is often cited above median level of reported research.
Susceptibility of hypomagnesemia in early life is not influenced by breast feeding.
Environmental and maternal constitutional factors have little or no impact on milk magnesium concentrations.
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INTRODUCTION
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The nutritional requirements of infants are based on composition of human milk. Published work on magnesium composition of human milk suggests consistency or small variations within studies during the first six months of lactation and rarely any change due to environmental or constitutional causes. Nevertheless, reference values cited or used as a paradigm for maternal and infant nutrition studies are often above median values reported in the literature. Reviews have reported concentrations of 30 [1,2] or even higher, such as 38 to 40 mg/L [3–6]. It is possible that some of these high values may be due to differences in methodology used in early publications.
Magnesium is the fourth most abundant cation in the human body after sodium, potassium and calcium. Most of the body magnesium is deposited in bone, and the adult skeleton stores 60% to 65% of the total body magnesium [7]. It composes 1.43% to 2.45% of the total mineral mass (ash) of milk [8–10]. On a dry-matter basis, its concentration ranges from 244 to 469 mg/kg of milk [11–13]. During lactation, bone is mobilized and exerts a marked influence on the availability of those macro-elements to the mineral pool that must supply the mammary gland. Besides sharing storage sites with calcium, magnesium metabolism interacts with calciotropic agents (calcitonin, parathyroid hormone, vitamin D) and estrogens [14,15].
Neonates are susceptible to hyper- [16] and hypomagnesemia [17]. Therefore, the understanding of milk magnesium composition is important for nutritional management during early life. Studies of magnesium composition of human milk cover a wide spectrum of environmental and constitutional factors. Such variables are discussed in this review, and, surprisingly, these variables had little impact on the magnesium concentrations in human milk.
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PREMATURITY
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The high nutritional requirements of preterm babies raised interest in studies of the composition of breast milk from mothers delivering premature infants. In spite of claims that preterm breast milk might have higher concentrations of nutrients, in the case of milk magnesium, results point to no significant difference between breast milk of term and preterm mothers. In fact, the range of variations of mean magnesium concentrations is comparable between term and preterm milk (Table 1). Butte et al. [18] were the only authors to report a statistically significant increase in milk magnesium of preterm mothers, while others showed no significant difference.
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Table 1. Summary of Mean Concentrations (mg/L or mg/kg) of Magnesium in Studies Comparing Milk of Mothers of Term and Preterm Infants
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The higher nutritional requirements due to higher rates of bone mineralization and growth of preterm infants are not related to maternal conditions regulating magnesium secretion in human milk. Variability in magnesium concentrations of breast milk cannot be attributed to maternal conditions related to the length of pregnancy.
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STAGE OF LACTATION
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In spite of a decrease of the mineral mass (ash) in breast milk as lactation progresses, the concentration of magnesium shows consistency. Tables 1, 2, 3 and 4 show milk magnesium studies at different stages of lactation. During the first six months of lactation there is an assortment of trends indicating a slight increase [19–27] or decrease [28–32] or no change [8–10,18,33–41] in milk magnesium concentrations. In prolonged lactation greater than six months, small changes may occur in milk magnesium, although within normal ranges [10,42,43]. Such changes can be attributed to changes in total mineral mass (ash), since magnesium as a percentage of total ash remains relatively constant up to the 12th month of lactation [10].
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Table 2. Summary of Mean Magnesium Concentrations (mg/L or mg/kg) in Milk of Mothers under Conditions which may Affect Magnesium Metabolism
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Table 3. Summary of Studies Showing Comparison between Countries, or Regions within Countries, of Magnesium Concentrations (mg/L or mg/kg) in Breast Milk
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Table 4. Summary of Studies Comparing the Effects of Drugs (Hormonal Contraceptives and Magnesium Sulfate) on Milk Magnesium Concentrations (mg/L)
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According to Fransson and Lonnerdal [44], most of the magnesium in breast milk is bound to low-molecular-weight fractions (53.6%) and proteins (43.8%), and only a small portion is present in milk fat (1.8%) and particles (0.8%). Sampling foremilk and hindmilk therefore does not seem to influence the concentrations of magnesium [45–47]. Cyclic changes in milk magnesium during the day were suggested by Karra and Kirksey [48], but were not confirmed by others [45,47].
The relative frequency of reported magnesium concentrations in human milk is shown in Fig. 1. The median magnesium concentration is 31 mg/L and the reported means range from 15 to 64 mg/L, with 75% of the values below 35 mg/L (Fig. 1).
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ALTERED MATERNAL METABOLIC CONDITIONS
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Several conditions which alter maternal metabolism do not seem to affect magnesium secretion (Table 2). Magnesium metabolism can be affected by changes in insulin production, which increases intracellular magnesium [49–50]. Indeed neonatal hypomagnesemia was associated with maternal diabetes mellitus [51]. However, Bitman et al. [52] showed that a milk magnesium concentration of 48.6 mg/L (2.0 mmol/L) in diabetic mothers was not significantly different from that in control mothers. Similar results were reported by Butte et al. [19]. Other types of metabolic condition, such as galactosemia [53], also did not show statistically significant changes in magnesium concentrations.
Adolescent pregnancy can be a risk factor for poor bone mineralization [54], and Lipsman et al. [24] reported that magnesium in breast milk of teenage mothers was lower than in that of adult mothers. However, maternal differences in number of children [55], undernutrition [40] and socioeconomic status [31,56] were not statistically significant for milk magnesium concentrations when compared with those of controls. In physiological situations of maximal exercise testing, the metabolic loss of magnesium also did not affect milk magnesium concentrations [57].
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ENVIRONMENTAL DIVERSITY AND MAGNESIUM INTAKE
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Environmental diversity, which encompasses differences in food composition as well as food preparation, which may affect magnesium bioavailability, is not a factor that influences milk magnesium composition.
The mean concentrations of milk magnesium found in studies from different regions, but within the same country or different countries reported in the same studies, are shown in Table 3 and demonstrate certain inherent variability. Parr et al. [58] reported that mean magnesium concentrations from Guatemala, Hungary, Nigeria, the Philippines, Sweden and Zaire ranged from 22.6 to 34.2 mg/L. Also regional differences, such as rural versus urban living, caused no difference in magnesium concentration of breast milk [59].
Magnesium intakes of Egyptian (mean 386 mg/d) and American mothers (range from 361 to 410 mg/d) were comparable, and milk magnesium was not significantly different []. Even when magnesium intake (353 mg/d) was significantly higher, such as with Nepalese compared to American mothers (248 mg/d), no significant differences were seen in milk magnesium concentrations [61]. Nepalese lactating mothers had an intake Ca:Mg ratio of 0.22, while the ratio for American mothers was 2.79. Nevertheless, the Ca:Mg in milk was respectively 5 and 4.4 [61].
Cases of dietary habits such as vegetarianism showed contradictory results. In spite of probable lower mineral bioavailability in vegetarian diets, Finley et al. [22] found that this dietary habit had no significant effect on milk composition. Milk magnesium of vegetarian mothers was 27.5 mg/L compared with 31.1 mg/L of controls. Both groups had a mean daily magnesium intake of 321 mg. Contrary to these findings, Dagnelie et al. [62] reported that milk of mothers consuming a macrobiotic diet showed less magnesium (31.1 mg/L) than milk of omnivore mothers (35.8 mg/L). In spite of this "low" milk magnesium from vegetarian mothers, the mean value was comparable to the median value (31 mg/L) compiled from other studies (Fig. 1).
Karra et al. [60] found a significant increase in milk magnesium in American mothers during the first three months of lactation, in spite of no corresponding increase in dietary magnesium intake. Others [26,36,48] also found no significant correlation between magnesium intake and its concentration in breast milk. A recent study by Spätling et al. [63] showed that a daily supplement of 20 mmol of Mg did not increase milk magnesium concentrations.
Magnesium deficiency is not common, and dietary intakes of mothers from less developed countries may be equivalent or even higher than those of mothers from industrialized countries [60,61]. Therefore, observations on magnesium deficiency during lactation can only be derived from animal studies. Buck and Bale [64] found that a magnesium-deficient diet did not change milk magnesium of dams, but caused a decrease in milk volume and pup growth.
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CALCIOTROPIC AGENTS
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Although magnesium is known to have a functional link with calciotropic hormones [14], only a few studies have explored the role of these agents with respect to milk magnesium. In spite of possible differences in vitamin D concentrations between milk of Black and Caucasian mothers [65], differences in milk magnesium between Bantu and white mothers were not significant [11]. In one case of a vitamin D supplemented mother, the range in milk magnesium (21.6 to 22.8 mg/L) was comparable to that of non-supplemented mothers (20.9 to 25.5 mg/L). Although Arver et al. [66] reported a significant correlation between immunoreactive calcitonin and magnesium inbreast milk, there are no studies demonstrating a consistent change in milk magnesium due to endocrine influence.
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MEDICATIONS
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Steroid hormones are known to affect the metabolism of magnesium throughout the menstrual cycle [15]. In early studies, hormonal contraceptives showed significant effects on magnesium metabolism [67], and since then there have been few studies of its effects on milk magnesium concentration. When taken before pregnancy, long term use of oral contraceptives (OC) did not affect magnesium secretion in milk of the following lactation [68]. When OC were taken during lactation, studies showed, at best, inconclusive results. Abdel Kader et al. [69] reported that OC significantly decreased milk magnesium, while Sinchai et al. [25] reported only a transient effect and Dorea [70] did not find any significant effect of hormonal contraceptives on milk magnesium.
The reason for such differences between studies was partly explored by Dorea [70]. Although all three studies were comparable in observation length and use of control groups, they differed in statistical analyses and principally in hormonal formulations (Table 4). In the study of Abdel Kader et al. [69], the hormonal formulations contained estrogens and progestagens in higher doses than the formulas employed by Sinchai et al. [25] and Dorea [70]. The effect of higher concentrations of hormones on magnesium metabolism cannot be ruled out. It is likely, however, that inherent variability may have compromised the statistical analysis. The difference in magnesium concentration within groups at the start of the study was of the same magnitude as the difference between groups that was claimed to be caused by the use of OC [69]. The control group, analyzed independently, showed no significant decrease in milk magnesium associated with stage of lactation, but the relative decrease in milk magnesium (20.6%) was of the same magnitude as the significant decrease (20.9%) claimed for the group taking Lyndiol 1.0 (lynestrenol 1 mg+mestranol 0.10 mg). The percent change (20.6%), observed by Abdel Kader et al. [69] in the control group, was greater than percent changes reported by either Dorea [70] or Sinchai et al. [26] (Table 4).
Hormonal contraceptives, known to either affect lactation [71] or bone metabolism (estrogens) in particular, could interact with other variables that need appropriate statistical evaluation. Neither Abdel Kader et al. [69] nor Sinchai et al. [25] employed a model which could handle statistical analysis that included intervening variables, such as time-dependent changes in milk magnesium and type and length of OC use. Employing such a model, Dorea [70] concluded that short-term use of OC did not affect magnesium concentrations in breast milk.
Postpartum preeclamptic patients who received magnesium sulfate therapy (load dose of 4 g, followed by a maintenance dose of 1 g/hour) for 24 hours showed a significant difference in milk magnesium (64 mg Mg/L) when compared with untreated controls (47.7 mg Mg/L). Magnesium clearance brought serum concentrations to control values within 24 hours after treatment. After day one of treatment both serum and colostrum magnesium concentrations were not statistically significant. During the treatment, milk:serum ratios were 1.82 and 2.62 respectively for treated and control groups [72].
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INFANT SUSCEPTIBILITY TO MILK MAGNESIUM
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Studies in adults which suggested that high calcium diets could be detrimental to magnesium status were reviewed by Whiting and Wood [73]. These authors concluded that high calcium diets did not alter magnesium status in spite of an apparent effect on magnesium absorption, which is counteracted by compensatory kidney regulation.
The fluctuations in magnesium intake, due to the wide range of milk magnesium concentrations (Table 5), does not seem to affect exclusively breast-fed infants. Studies in very low birth weight infants showed that magnesium absorption from fortified human milk is estimated at 86% [28,74]. The interaction between calcium, phosphorus and magnesium in milk formulas was studied by Giles et al. [75] in premature babies. Although these authors suggested that the high calcium concentrations had a negative effect on magnesium absorption, such interactions were not observed by Liu et al. [74].
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Table 5. Summary of Studies Reporting Magnesium Concentration (mg/L) in Breast Milk from Different Parts of the World
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In spite of a wide variation of calcium concentrations in human milk [76], milk calcium at extreme concentrations of 400 mg/L (median 256 mg/L) occurs in less than 15% of studies and is well below cow’s milk formulas [6]. Even at these concentrations it is unlikely that breast-milk calcium could negatively interact with magnesium in the exclusively breast-fed infant. Studies on low-birth-weight infants indicate that human milk provides adequate amounts of magnesium to achieve intrauterine accretion rates, although retention can be increased as a function of magnesium supplementation [77].
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CONCLUSIONS
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Notwithstanding numerous publications reporting magnesium concentrations in human milk, most values used as references were above the reported median concentration of 31 mg/L. Ninety percent of reported means fell within range of 20 to 40 mg/L. Variations observed in milk magnesium concentrations among studies do not seem to be modulated by either environmental or constitutional factors. Dietary magnesium intake or agents that could affect its metabolism showed no systematic effects on milk magnesium. Magnesium in human milk is well absorbed, and there are no reports of limitations of breast milk in providing adequate magnesium nutrition for the exclusively breast-fed infant. Occurrence of neonatal hypo- or hypermagnesemia is in no way associated with concentrations of magnesium in breast-milk. Although breast-milk magnesium concentrations may vary between mothers, its concentration is relatively stable within mothers. Controlling mechanisms at the mammary gland seem to operate well under a variety of dietary magnesium intakes.
Received March 1, 1999.
Accepted November 1, 1999.
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