Breastfeeding and fasting during Ramadan

Breastfeeding and fasting during Ramadan

“Fast for a specified number of days [during the month of Ramadan]. Whoever of you is sick or travelling and does not fast, let him fast the same number of days later”
The Koran. Surah 2, Ayah, 184

Yasmin Paricio Burtin, journalist, communication and sponsorship officer in APILAM
Dr. José María Paricio Talayero, pediatrician, President of APILAM

Ramadan, the holy month of Islam, coincides with the ninth month of the Islamic lunar calendar. During this period Muslim adults fast: from dawn to sunset they do not eat or drink, take medication orally, or smoke and abstain from sexual intercourse. Everyone should fast except those who are ill or travelling (Bajaj 2012, Rashid, 2007).

Based on the lunar calendar, each year Ramadan falls eleven days earlier, and depending on the season, the duration of daily fasting varies annually: fasting in summer is longer, while in winter it is shorter (Rashid 2007 ). The duration of fasting also varies according to the geographical position of the country, ranging from 10 to 19 hours a day (Bajaj 2012) and even longer in Scandinavian countries such as Sweden (Al Jazeera 2014).

But what do breastfeeding Muslim women do during this holy month? Should they fast? Do they fast? Is fasting safe for the baby and / or breastfeeding mothers? Does fasting affect the composition of breast milk? Does milk production decrease?

In this article we will address these issues drawing on published scientific studies on breastfeeding and fasting during Ramadan.

1.8 billion Muslim people in the world, half of whom are women
Fasting during Ramadan is one of the five pillars of Islam (Bajaj 2012), a religion professed by 24% of the world's population: about 1.8 billion people, according to estimates by the Pew Research Center (PRC 2017/05/26) and of which approximately half are women (Bajaj 2012).

It is the second largest religion in the world, after Christianity, and the fastest growing religion (PRC, 2017/05/26).  In the period between 2010 and 2015, births among the Muslim population accounted for 31% of the world's population, with a fertility rate of 2.9 children per woman (PRC 2017/04/05).

The majority of Muslims, 62%, live in Asia-Pacific, 19.8% in the Middle East and North Africa, 15.5% in sub-Saharan Africa, 2.7% in Europe, 0.2% in North America and almost 0.1% in Latin America and the Caribbean (PRC, 2015/04/02-a).

It is estimated that by 2020 there will be some 54.4 million Muslims in Europe, of whom, excluding Russia, most will live in Germany (5.5 million), France (5.4 million), United Kingdom (3.9 million), Italy (2.9 million), Albania (2.6 million), Kosovo (1.7 million), Bosnia-Herzegovina (1.6 million), Spain (1.6 million) and the Netherlands (1.2 million) (PRC, 2015/04/02-b).

Should breastfeeding Muslim women fast during Ramadan?
Breastfeeding has a religious basis in Islam (Shaikh 2006), which recommends breastfeeding for two years. Weaning before two years of age must be decided by the father and mother, and wet nurses are allowed as long as they are paid as agreed (The Koran, Surah 2, Ayah 233).

Although people who are ill or are travelling are exempt from fasting, there is controversy over whether breastfeeding mothers should or should not fast. For some authors they would be exempt in any situation (Khalife 2015, Mubeen 2012, Shaikh 2006, Andrews 1997), others are only excused if there is good reason to believe that fasting can cause them or their babies some harm (Rashid 2007, Shaikh 2006). In any case, fasting is postponed to a later date (Shaikh 2006, Andrews 1997).

Do breastfeeding Muslim women fast during Ramadan?
Most breastfeeding mothers fast during Ramadan (Khalife 2015, Kridli 2011). In Canada, most prefer to fast during Ramadan with their community rather than to do it alone later (Jessri 2013, Andrews 1997). In Turkey, 69% of breastfeeding mothers fast regardless of level of education (Rashid 2007). 

In Pakistan, up to 88% of pregnant women practice religious fasting (Mubeen 2012) and in some areas of rural Africa 100% of breastfeeding mothers fast during Ramadan (Prentice 1983).

Are there changes in breast milk due to fasting during Ramadan?
There is a lack of knowledge and research on possible changes in breast milk and on the safety and impact of breastfeeding due to Ramadan fasting (Bajaj 2012, Kridli 2011).

In conditions of extreme heat (Gambia), significant changes in milk composition (increase of sodium and osmolarity and decrease of lactose) have been found during fasting hours (Prentice 1984).

A decrease in some micronutrients such as zinc and magnesium has been observed (Rakicioğlu 2006), but in general, although breastfeeding mothers experience a mild degree of dehydration during fasting hours and in extreme heat conditions, -4.9% on average, slightly higher than that of non-breastfeeding women in the same period, -3.8% (Prentice 1984), they do not undergo any clinically significant metabolic or physiological disorder (Rakicioğlu 2006, Andrews 1997, Prentice 1984).

Does milk production fall during fasting? Does it affect the growth of infants? Does it affect the mother?
It has been reported that one in five women report decreased milk production during Ramadan fasting and there may be an increase in milk supplements given to infants younger than six months old (Bajaj 2012, Ertem 2001).

Since changes in the macronutrient composition of breast milk are not of major clinical significance, the growth of infants is not affected (Rakicioğlu 2006, Andrews 1997).

Nor do the levels of prolactin or other hormones involved or not in the reproduction process change  in the mother (Cağlayan 2014, Prentice 1984, Prentice 1983). Moreover, breastfeeding mothers gain on average 1 kg following Ramadan without significant changes in body mass index (Rakicioğlu 2006).

Breastfeeding mothers who choose to fast should be advised to drink plenty of fluids and eat nutritious foods between dinner and dawn in order to compensate for daytime losses, and should avoid excessive daytime activity and know the warning signs that would justify breaking the fast, such as extreme fatigue, dizziness, nausea or vomiting (Khalife 2015), whilst monitoring milk production (Bajaj 2012).

Some authors, doctors and pediatricians, advise breastfeeding mothers against fasting (Rakicioğlu 2006) especially when exclusively breastfeeding infants under 6 months (Bajaj 2012).

Maternal and child health care providers should be well informed about the religious and cultural phenomena of Islam and understand the effects of fasting during Ramadan in order to use appropriate methods to prevent possible adverse effects (Ertem 2001).

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