Zinc supplementation in lactating women: evidence for mammary control of zinc secretion

Micronutrients in Human Milk: Analytical Methods

Exclusive breastfeeding is recommended by the WHO for the first 6 mo of life because human milk protects against gastrointestinal infections and supplies balanced and adequate nutrient contents to the infant. However, reliable data on micronutrient concentrations in human milk are sparse, especially because some micronutrients are affected by maternal diet. Microbiological and competitive protein-binding assays, nuclear magnetic resonance or inductively coupled plasma spectroscopy, and chromatographic analyses are among the methods that have been applied to human-milk micronutrient analysis. However, the validation or evaluation of analytical methods in terms of their suitability for the complex human-milk matrix has been commonly ignored in reports, even though the human-milk matrix differs vastly from blood, plasma, or urine matrixes. Thus, information on the validity, accuracy, and sensitivity of the methods is essential for the estimation of infant and maternal intake requirements to support and maintain adequate milk micronutrient concentrations for healthy infant growth and development. In this review, we summarize current knowledge on methods used for analyzing water- and fat-soluble vitamins as well as iron, copper, zinc, iodine, and selenium in human milk and their different forms in milk; the tools available for quality control and assurance; and guidance for preanalytical considerations. Finally, we recommend preferred methodologic approaches for analysis of specific milk micronutrients.

Premutation in the Fragile X Mental Retardation 1 (FMR1) Gene Affects Maternal Zn-milk and Perinatal Brain Bioenergetics and Scaffolding

Fragile X premutation alleles have 55–200 CGG repeats in the 5′ UTR of the FMR1 gene. Altered zinc (Zn) homeostasis has been reported in fibroblasts from >60 years old premutation carriers, in which Zn supplementation significantly restored Zn-dependent mitochondrial protein import/processing and function. Given that mitochondria play a critical role in synaptic transmission, brain function, and cognition, we tested FMRP protein expression, brain bioenergetics, and expression of the Zn-dependent synaptic scaffolding protein SH3 and multiple ankyrin repeat domains 3 (Shank3) in a knock-in (KI) premutation mouse model with 180 CGG repeats. Mitochondrial outcomes correlated with FMRP protein expression (but not FMR1 gene expression) in KI mice and human fibroblasts from carriers of the pre- and full-mutation. Significant deficits in brain bioenergetics, Zn levels, and Shank3 protein expression were observed in the Zn-rich regions KI hippocampus and cerebellum at PND21, with some of these effects lasting into adulthood (PND210). A strong genotype × age interaction was observed for most of the outcomes tested in hippocampus and cerebellum, whereas in cortex, age played a major role. Given that the most significant effects were observed at the end of the lactation period, we hypothesized that KI milk might have a role at compounding the deleterious effects on the FMR1 genetic background. A higher gene expression of ZnT4 and ZnT6, Zn transporters abundant in brain and lactating mammary glands, was observed in the latter tissue of KI dams. A cross-fostering experiment allowed improving cortex bioenergetics in KI pups nursing on WT milk. Conversely, WT pups nursing on KI milk showed deficits in hippocampus and cerebellum bioenergetics. A highly significant milk type × genotype interaction was observed for all three-brain regions, being cortex the most influenced. Finally, lower milk-Zn levels were recorded in milk from lactating women carrying the premutation as well as other Zn-related outcomes (Zn-dependent alkaline phosphatase activity and lactose biosynthesis—whose limiting step is the Zn-dependent β-1,4-galactosyltransferase). In premutation carriers, altered Zn homeostasis, brain bioenergetics and Shank3 levels could be compounded by Zn-deficient milk, increasing the risk of developing emotional and neurological/cognitive problems and/or FXTAS later in life.

Mammary gland zinc metabolism: regulation and dysregulation

Zinc (Zn) is required for numerous metabolic processes serving both a structural and catalytic role. The mammary gland has a unique Zn requirement resulting from the need to also transfer an extraordinary amount of Zn into milk (~0.5-1 mg Zn/day) during lactation. Impairments in this process can result in severe Zn deficiency in the nursing offspring which has adverse consequences with respect to growth and development. Moreover, dysregulated mammary gland Zn metabolism has recently been implicated in breast cancer transition, progression and metastasis, thus there is a critical need to understand the molecular mechanisms which underlie these observations. Tight regulation of Zn transporting mechanisms is critical to providing an extraordinary amount of Zn for secretion into milk as well as maintaining optimal cellular function. Expression of numerous Zn transporters has been detected in mammary gland or cultured breast cells; however, understanding the molecular mechanisms which regulate mammary Zn metabolism as well as the etiology and downstream consequences resulting from their dysregulation is largely not understood. In this review, we will summarize the current understanding of the regulation of mammary gland Zn metabolism and its regulation by reproductive hormones, with a discussion of the dysregulation of this process in breast cancer.

Trace element transport in the mammary gland

The mammary gland has a remarkable capacity to adapt to maternal deficiency or excess of iron, copper, and zinc and to homeostatically control milk concentrations of these essential nutrients. Similarly, it can regulate changes in concentrations of iron, copper, and zinc change during lactation. For iron, this regulation is achieved by transferrin receptor, DMT1, and ferroportin, whereas mammary gland copper metabolism is regulated by Ctr1, ATP7A, and ATP7B. Zinc homeostasis is complex, involving both zinc importers (Zip3) and zinc exporters (ZnT-1, ZnT-2, and ZnT-4). Both transcriptional and post-translational regulation can affect protein abundance and cellular localization of these transporters, finely orchestrating uptake, intracellular trafficking, and secretion of iron, copper, and zinc. The control of mammary gland uptake and milk secretion of iron, copper, and zinc protects both the mammary gland and the breast-fed infant against deficiency and excess of these nutrients.

Effects of dietary zinc supplement during lactation on longitudinal changes in plasma and milk zinc concentration

Effects of dietary zinc supplement during lactation on maternal zinc plasma and milk zinc concentration through 5 months of lactation were examined. One hundred and thirty eight healthy lactating mothers received a weekly 100 mg elemental zinc supplement (ZS, n = 67) or placebo (PG, n = 71) starting one week postpartum in a double blind, randomized design. Milk and plasma zinc concentrations were determined by atomic absorption spectrophotometer. During the course of study, there was not a significantly difference between ZG and PG groups in dietary zinc and energy intake. The mean plasma zinc concentration at 1st week and 5th month were 134 +/- 49.1 and 115.6 +/- 23 microg dL(-1) (PV = 0.005) for PG group, respectively; that of the ZG group these figures were 124.9 +/- 52.8 and 121 +/- 27.1 microg dL(-1) (PV = 0.38), respectively. The mean serum alkaline phosphatase concentration at 1st week and 5th month were 94.8 +/- 37 and 92.6 +/- 29.9 iu L(-1) for PG group, respectively; that of the ZG group these fissures were 90.5 +/- 36 and 90 +/- 29 iu L(-1) (PV = 0.21), respectively. Milk zinc concentration declined significantly over the course of study for two groups, with the sharpest decline occurring during the first 2 months. The mean monthly zinc concentration of ZG group declined from 310 +/- 138 at 1st week to 118 +/- 64 microg dL(-1) at 5th month (declined by 52%). Corresponding means for PG group were 322 +/- 161 and 109 +/- 70 microg dL(-1) (declined by 60%), respectively. Milk zinc concentration significantly different between two groups at 3 and 4 months. A similar study, however, with different zinc dose and administration manner, in zinc marginal deficient lactating mothers is needed to assess the impact of zinc supplementation on milk zinc concentrations.

Complementary feeding: clinically relevant factors affecting timing and composition

Exclusive breastfeeding for the first 6 mo of life followed by optimal complementary feeding are critical public health measures for reducing and preventing morbidity and mortality in young children. Clinical factors, such as birth weight, prematurity, and illness, that affect the iron and zinc requirements of younger infants are discussed. Maternal diet and nutritional status do not have a strong effect on the mineral content of human milk, but physiologic changes in milk and the infants' status determine the dependence of the infant on complementary foods in addition to human milk to meet iron and zinc requirements after 6 mo. The nature of zinc absorption, which is suitably characterized by saturation response modeling, dictates that plant-based diets, which are low in zinc, are associated with low absolute daily absorbed zinc, which is inadequate to meet requirements. Foods with a higher zinc content, such as meats, are much more likely to be sufficient to meet dietary requirements. Current plant-based complementary feeding patterns for older fully breastfed infants in both developed and developing countries pose a risk of zinc deficiency. The strong rationale for the potential benefits of providing meat as an early complementary food, and the examples of successful intervention programs, provide potent incentives to pursue broader implementation programs, with concurrent rigorous evaluation of both efficacy and effectiveness.

Molecular regulation of milk trace mineral homeostasis

The regulation of milk trace mineral homeostasis requires the temporal integration of three main processes, (A) mineral uptake into the secretory mammary epithelial cell (MEC); followed by (B) mineral secretion from MEC into the alveoli lumen of the mammary gland for sequestration in milk; and then (C) milk release in response to suckling. Trace mineral requirements of term infants are generally met by exclusive breast-feeding through about the first 6 months of life and although milk zinc (Zn), iron (Fe), and copper (Cu) concentrations are relatively refractory to maternal trace mineral status, they normally decline throughout lactation. Recently, Zn-, Fe- and Cu-specific transporters have been identified that regulate trace element uptake and efflux in various cell types; however, there is currently little information available regarding the processes through which the mammary gland regulates milk trace mineral transport. The homology of trace mineral transporters between species permits the utilization of rodent models to examine the regulation of mammary gland mineral transport. Therefore, we have used the lactating rat to determine changes in mammary gland Zn, Fe and Cu transporter expression and localization that occur throughout lactation and in response to maternal trace mineral deficiency in hope of elucidating some of the changes which occur during mammary gland trace element homeostasis and also may be occurring in lactating women.

Zn Transporter Levels and Localization Change Throughout Lactation in Rat Mammary Gland and Are Regulated by Zn in Mammary Cells

Mechanisms regulating the decrease in milk zinc (Zn) concentration that occurs during the course of lactation are currently unknown. We demonstrated Zn transporter expression (Zip3, ZnT-1, ZnT-2 and ZnT-4) in rat mammary gland during mid-lactation and we hypothesize that changes in the levels and localization of these transporters play a role in the longitudinal decrease in milk Zn concentration. Furthermore, we suggest that cellular Zn levels can mediate these responses and determined the effects of Zn exposure on Zn transporter expression and localization in cultured mouse mammary epithelial (HC11) cells. Although the milk Zn level declined, mammary gland Zn, ZnT-1 and ZnT-2 mRNA levels increased through mid-lactation; ZnT-4 was unaltered and ZIP3 decreased. Zip3 protein decreased through lactation and localized to the basolateral membrane of rat mammary cells. Although ZnT-1 and ZnT-4 protein increased, data indicate that these proteins are members of larger complexes whose levels change throughout lactation. ZnT-2 protein decreased, whereas apical membrane staining of ZnT-1, ZnT-2 and ZnT-4 was low by the end of lactation. Zn-treated HC11 cells had lower 65Zn uptake and ZIP3 mRNA levels and higher 65Zn export, ZnT-1 and ZnT-2 mRNA levels than untreated cells. Zn treatment resulted in relocalization from the plasma membrane (Zip3) or Golgi apparatus (ZnT-4) to an intracellular compartment, from an intracellular compartment toward the plasma membrane (ZnT-2) or from a perinuclear to an intracellular compartment (ZnT-1). The results from this study indicate that the decrease in milk Zn concentration that occurs throughout lactation is in part a result of changing Zn transporter protein levels and cellular localization, possibly as a consequence of increasing mammary gland Zn concentration.

Zinc transporters in the rat mammary gland respond to marginal zinc and vitamin A intakes during lactation

Marginal intake of zinc and vitamin A is common during lactation and a deficiency of one micronutrient can result in a secondary deficiency of the other. However, the resistance of milk zinc (Zn) concentration to changes in dietary Zn or vitamin A indicates tight regulation of mammary gland Zn transport. Although several mammalian proteins have been identified and implicated in Zn transport, the mechanisms responsible for mammary gland Zn transport and their regulation by dietary Zn and vitamin A are unknown. In this study, we identified mammary gland Zn transporters and determined effects of marginal Zn and vitamin A intakes on their levels. Rats were fed a control [25 mg Zn/kg, 4 retinol equivalents (RE)/g], a low Zn (10 mg Zn/kg), a low vitamin A (0.4 RE/g), or a low Zn (10 mg Zn/kg) and vitamin A (0.4 RE/g) diet throughout lactation. ZnT-1, ZnT-2 and ZnT-4 were identified in the mammary gland and localized to the serosal membrane (ZnT-1) or intracellularly (ZnT-2 and ZnT-4) by immunostaining. Rats fed a low Zn or low vitamin A diet had lower ZnT-1 protein and higher ZnT-4 mRNA expression and protein levels compared with controls. There was a significant interaction between dietary Zn and vitamin A on zinc transporter mRNA expression and protein levels. Although total mammary gland Zn was not affected, mammary gland metallothionein levels were lower in rats fed low Zn and higher in rats fed low vitamin A, suggesting different mechanisms regulating zinc transporter levels. These results indicate that milk Zn level is maintained through coordinated regulation of mammary gland zinc transporters and documents an effect of vitamin A on zinc homeostasis at the molecular level during lactation.

Concentrations of iron, copper and zinc in human milk and powdered infant formula

Concentrations of iron, copper and zinc were determined in 56 samples of mature human milk from Canarian women and 5 samples of powdered infant formula. According to the literature our data fall within the normal limits in each kind of milk. The mean concentration of Fe, Cu and Zn of powdered infant formula was significantly higher than those concentrations found in the human milks. Significant differences among the concentrations of the studied metals for the milks of considered mothers were observed. The Fe, Cu and Zn intakes of infants fed with human milk are lower than the requirements recommended by the Food and Nutrition Board (1989). However, the infants fed with powdered infant formula had consumed an adequate intake of Fe and Cu. A progressive decrease of the metal concentrations with the lactation stage was observed. The human milk obtained in spring presented Fe and Zn concentrations lower than in autumn, which could be due to changes in nutritional habits of the mothers. Age of mother and number of previous children seem to influence the Zn and Cu concentrations of human milk.

Dietary supplements for the lactating mother: influence on the trace element content of milk

Milk production is a complex process where nutritional factors interact with structural hormonal and behavioural influences. In recent years important advances have been made in understanding the role of the nutritional status of lactating women on the outcome of breastfeeding. Many questions remain unanswered about the exact requirement of trace elements for lactating mothers. The effect of dietary zinc, copper and iodine supplements on the milk concentration of these micronutrients was studied. The supplementation trial employed a specific balanced nutritional supplement prepared for the nursing mothers. The study was carried out on women living in Ferrara and its surrounding area. The population under study was healthy Italian mothers, of good socioeconomic status, and their normal infants. In total, 32 women were enrolled in the study and 22 completed it. The infants (9F, 13M) were full-term, healthy singletons and were put to breast within 12 h of birth. All women who finished the study completed a 3 d dietary record. Nutrient analysis revealed the following mean daily dietary trace element intake in the lactating mothers: zinc = 12 mg, copper = 1.4 mg and iodine = 145 microg. The zinc and copper dietary intake was in agreement with the daily intake proposed for nursing Italian mothers, while the daily intake of iodine was below the recommended intake of 200 microg. The breastfeeding mothers were placed in 2 groups, with 7 primiparas and 4 multiparas per group: lactating women eating a traditional Italian diet without vitamin and mineral supplements, and lactating women enrolled in the nutrification programme and given a nutritional supplement to their traditional diet. The supplement (PerMamma Abbott) provided 20mg zinc sulfate, 2mg copper sulfate and 116 microg potassium iodide. These quantities cover about 60-90% of the recommended intake for nursing Italian mothers. Samples of 10 ml of milk were collected at 3, 30, 90d postpartum. Zinc milk concentrations declined significantly over the study period for all lactating subjects, without differences in the rate of decline between the women who started supplementation during lactation and those who did not. Copper did not change during the first month of lactation, then declined at day 90 in supplemented and unsupplemented women, without significant differences between the two groups. An early sharp decline in milk iodine occurred in all lactating subjects, independently of iodine supplementation. After the first month of lactation breast milk iodide levels remained stable in all subjects under study. No significant differences between the two study groups were observed. The lack of correlation between the iodide level in breast milk and maternal dietary intake of iodine is not in agreement with previously published reports. The present results indicate that in healthy, well-nourished lactating Italian women, whose diet is adequate, the levels of zinc, copper and iodine in milk are not influenced by short-term supplementary intakes and that the milk levels of the trace elements studied are maintained over different levels of intake. Further research and examination by longitudinal studies are needed to establish the exact relationship between the amount of iodine furnished to the nursing mother and the iodine content of human milk. The role of compensatory homeostatic mechanisms which act during lactation needs further consideration and closer scrutiny.

Zinc transfer to the breastfed infant

Zinc is a micronutrient which is critical to normal growth and development. Zinc concentrations in human milk decline sharply during the early months post partum, regardless of maternal zinc intake. Milk zinc concentrations do not increase in response to increased maternal zinc intake if maternal zinc status is adequate. The mechanism of zinc secretion into milk is not fully understood. A mutation in the gene for a zinc transporter protein may account for abnormally low milk zinc concentrations associated with severe zinc deficiency in breastfed infants. The zinc requirements of breastfed infants are generally met with exclusive breastfeeding through 5-6 months of age, due to the favorable bioavailability of the zinc in human milk. Because of declining milk zinc concentrations and intake, zinc status in exclusively breastfed infants is likely to become marginal beyond 6 months of age, and may become suboptimal for some infants if exclusive breastfeeding continues. The choice of complementary foods is important to maintain adequate zinc status in breastfed infants after 6 months.

Identification of an alpha2-macroglobulin receptor in human mammary epithelial cells

Several cases of zinc (Zn) deficiency in human infants caused by abnormally low concentrations of Zn in breast milk were recently reported, the underlying mechanism of which is not known. Alpha2-macroglobulin (alpha2-M), a major Zn-binding ligand in serum, presents a potential vehicle for mammary Zn uptake. This study was conducted to determine if an alpha2-M receptor is present in human mammary epithelial cells, where it may be involved in the endocytosis of alpha2-M into the mammary gland. Normal human mammary epithelial cells were grown to confluency in serum-free medium. For all binding and uptake studies, alpha2-M, preactivated with methylamine and labeled with 125I, was added to cells for varied lengths of time to determine saturation over time and at varied concentrations to determine saturation over increasing concentration of ligand. Nonspecific and competitive binding were measured by addition of a 100-fold molar excess of unlabeled alpha2-M and serum albumin or lactoferrin, respectively. Binding at 4 degreesC was specific for alpha2-M and approached saturation kinetics at 56 nmol/L. Scatchard plot analysis of the binding data demonstrated more than one binding site: a high affinity, saturable binding site and a low affinity, nonsaturable binding site. Uptake of alpha2-M at 37 degreesC was rapid and continuous over increasing concentrations of alpha2-M, and internalized alpha2-M was rapidly degraded. Results from this study present evidence for receptor-mediated uptake of alpha2-M in human mammary epithelial cells, which in turn, provides a potential mechanism for Zn acquisition by the cell.

Properties of human milk and their relationship with maternal nutrition

The composition of human milk varies over the course of lactation and in each individual. The volume of breast milk produced is related to the weight of the infant. Human milk is markedly different from cows' milk, both in terms of macronutrients and micronutrients. This includes the types of fatty acids present and factors affecting their absorption. The types of proteins present and their relative proportions and both qualitative and quantitative differences in the non-protein nitrogen fraction. There is much less lactose in cows' milk than breast milk and the oligosaccharide fraction is very different. Their are major differences in content and absorption rates of vitamins and minerals from breast milk compared to cows' milk or formula milk. Vitamin D and vitamin K status are possible problems for the breast-fed infant in certain circumstances. The nutritional status of the mother appears to influence fat concentration and thus the energy content of breast milk as well as its fatty acid composition and immunological properties. There is no coherent evidence, however, that the protein or lactose concentrations are greatly affected. There is some evidence that the concentration of vitamins in the breast milk are influenced by the mother's intake. Minerals are less variable, with the exception of selenium. The response of the infant to human and formula milk differs with respect to endocrine function, stool motility, immune function and renal function. Infant formula milks are designed to mimic human milk as much as possible, but this is unlikely to ever be completely successful. A number of important compositional differences between human milk and formula milk remain. This includes the types and proportions of fatty acids present (which may be of developmental importance), the nature of the non-protein nitrogen component (also possible developmental importance) and the presence of immunoglobulins and fibronectin (which may protect the infant against infection).

Zinc, copper and selenium in reproduction

Of the nine biological trace elements, zinc, copper and selenium are important in reproduction in males and females. Zinc content is high in the adult testis, and the prostate has a higher concentration of zinc than any other organ of the body. Zinc deficiency first impairs angiotensin converting enzyme (ACE) activity, and this in turn leads to depletion of testosterone and inhibition of spermatogenesis. Defects in spermatozoa are frequently observed in the zinc-deficient rat. Zinc is thought to help to extend the functional life span of the ejaculated spermatozoa. Zinc deficiency in the female can lead to such problems as impaired synthesis/secretion of (FSH) and (LH), abnormal ovarian development, disruption of the estrous cycle, frequent abortion, a prolonged gestation period, teratogenicity, stillbirths, difficulty in parturition, pre-eclampsia, toxemia and low birth weights of infants. The level of testosterone in the male has been suggested to play a role in the severity of copper deficiency. Copper-deficient female rats are protected against mortality due to copper deficiency, and the protection has been suggested to be provided by estrogens, since estrogens alter the subcellular distribution of copper in the liver and increase plasma copper levels by inducing ceruloplasmin synthesis. The selenium content of male gonads increases during pubertal maturation. Selenium is localized in the mitochondrial capsule protein (MCP) of the midpiece. Maximal incorporation in MCP occurs at steps 7 and 12 of spermatogenesis and uptake decreases by step 15. Selenium deficiency in females results in infertility, abortions and retention of the placenta. The newborns from a selenium-deficient mother suffer from muscular weakness, but the concentration of selenium during pregnancy does not have any effect on the weight of the baby or length of pregnancy. The selenium requirements of a pregnant and lactating mother are increased as a result of selenium transport to the fetus via the placenta and to the infant via breast milk.

Breast milk as a source of vitamins, essential minerals and trace elements

Human breast milk provides all of the vitamins and essential minerals and trace elements (micronutrients) that are required by the normal term infant, until weaning. With a few exceptions, excessive micronutrient supplies to the mother, or a moderate deficiency in her diet, do not greatly alter the supply to the infant. Thus, the infant is well-protected by maternal homeostatic processes, although the mechanisms of these are not yet well understood. Considerable progressive changes in concentration occur for some of the micronutrients during the course of lactation. Because the concentration of these nutrients, and of other substances that modify their absorption by the infant, such as binding proteins, differs considerably between human milk, animal milk and, hence, commercial milk formulae, there is great interest in the quantitative significance of micronutrient supplies, and their variability in breast milk, in the quest for improvement of commercial formulations. The aim of this review is to summarize the available information about the factors that determine breast milk contents of micronutrients.