1. Macronutrients
As is already well known, HBM contains about 87%–88% water, and it has a specific gravity of 1.030, osmolarity of about 286 mOsm/L, and 124-g/L solid components as macronutrients, including about 7% (60–70 g/L) carbohydrates, 1% (8–10 g/L) protein, and 3.8% (35–40 g/L) fat [10-13] (Table 1). Typically, mature milk contains 65–70 kcal per 100 mL of energy, and about 50% of the total calorie supply is fat and 40% is carbohydrates [14]. However, unlike infant formulas, which have a narrow range of composition guidelines based on strict criteria for health effects on infants, the nutrient composition of HBM is dynamic for various reasons [14-16]. The composition of HBM may vary depending on the maternal diet, mammary gland physiology, maternal health, and many other environmental factors [13,14]. In addition, it may vary depending on prematurity, on whether it is foremilk or hindmilk, and on whether it is colostrum, transitional milk, or mature milk [17]. It may vary depending on the processing conditions, such as storage, pasteurization, and containers [18,19]. In the case of foremilk released by the mammary gland, the fat content is relatively low and increases with feeding, whereas hindmilk has higher fat content. The protein and lactose contents are not significantly different between them. Colostrum is low in fat but high in protein (10%) and is relatively rich in immune-protective components, such as immunoglobulin A (IgA) and lactoferrin, which help prevent neonatal infections.
1) Carbohydrates
Carbohydrates are the most prominent macronutrient in HBM and plays an important role in infant’s nutrition, in developing the physiological function of the entire gastrointestinal tract right from birth, and in maintaining the composition of the intestinal microbiota [20,21]. Most humans ingest carbohydrates in the form of glucose, whereas infants, who have not yet developed the gastrointestinal tract, ingest carbohydrates in the form of lactose. Thus, lactose is the major carbohydrate constituent of HBM and is the most abundant nutrient in breast milk. Lactose is digested by lactase-phlorizin hydrolase, also called lactase, which is present on the apical surface of enterocytes in the small intestinal brush border; lactose is readily digested in almost all infants [12]. However, the lack of enzymes can cause various symptoms, such as lactose intolerance or malabsorption. Unlike protein and fat, colostrum contains relatively fairly constant lactose with time [15,22]. A constant level of lactose is important for maintaining a constant osmotic pressure in HBM. In addition, carbohydrate-based bioactive components, such as oligosaccharides, are attached to lactose; this aids in the absorption of minerals and calcium [15]. The levels of free glucose and other glucose metabolites in HBM are low; thus, their nutritional significance is negligible in infants [23].
Highly complex HMOs are the second most abundant carbohydrate in HBM after lactose and the third most abundant solid component [24,25]. HMOs make up about 20% of the total HBM carbohydrates and are present in a concentration of 12–14 g/L in mature milk and >20 g/L in colostrum [24]. Known as “gynolactose” by L'espagnol and Plinowski in the 1930s, more than 150 HMO structures have been described to date [26]. Interest in HMOs has been increasing in recent years not only for the nutrition of infants but also for commercial purposes. HMOsare produced only in lactating mammary glands, which are not found in infant formulas, but recently, various types of oligosaccharides have been added to infant formulas [6,7]. Immediately after birth, the gut is sterile, but to prevent various infections after birth, the infant intestine must adapt to various circumstances and acquire an immune system. While direct ingestion of various bioactive compounds in HBM affects immunity, acquisition of intestinal colonization as an antimicrobial factor is also important [27]. Unlike lactose, which is easily digested, HMOs reache the colon in almost intact form due to their limited digestion; HMOs are known to play an important prebiotic role in the development of gut microbiota in early stages after birth [28]. In various previous studies, HMOs have been shown to reduce the duration of diarrhea and have a positive effect on the growth of bifidobacteria [29-33]. They also play an important role as an energy source for enterocytes and are associated with the production of short-chain fatty acids, which are key signaling molecules for maintaining gut health [28]. These short-chain fatty acids are known to inhibit the growth of potentially harmful gut microbiota by reducing intestinal pH [34]. In addition to this indirect role, some HMOs are thought to be involved in various systemic circulations to regulate direct immune responses [28]. In various studies of human infants, on comparing HMOs and infant formulas, the former also showed positive effects against infections, such as campylobacter. However, various studies are being conducted because much research on infant health is still lacking.
2) Protein
Protein is a major component that functions and organizes all cells in the human body, and sufficient protein supply is essential for growth, development, and function. The protein of HBM comprises a mixture of whey and casein, and various peptides. Casein is micellar and is present in the form of clots or curd in the stomach and is not easily dissolved. Whey is in liquid form and is easy to digest [14]. The whey/casein ratio varies according to the time of breast milk. In colostrum, the whey/casein ratio is absolutely high at almost 90:10, but this gradually changes to 60:40 in mature milk. Nevertheless, the proportion of whey is relatively higher in HBM than in infant formula, wherein it is about 20% [11,35]. Casein exists as alpha, beta, gamma, and kappa casein. Alpha casein is abundant in bovine milk and is rarely present in HBM [13,36]. Casein of HBM is more easily digested in the form of looser micelles and softer curd by carboxypeptidase, which regulates intestinal motility and aids calcium absorption. Lönnerdal et al. [37] reported that low casein proportion in HBM is associated with slower growth in breastfed infants. Representative whey proteins of HBM are alpha-lactalbumin, lactoferrin, and secretory IgA [14]. Among these, alpha-lactalbumin constitutes 40% of the whey protein of HBM, but beta-lactoglobulin is the representative whey protein of bovine milk and is absent in HBM [37]. Alpha-lactalbumin aids in the synthesis of lactose in mammary glands and in the supply of essential amino acids and absorption of minerals and trace elements in infants [38]. It also plays a role in the immune system and antibacterial properties. Lactoferrin and lysozyme inhibit the spread of potentially pathogenic bacteria, and IgA protects intestinal mucosa and destroys bacteria [14].
Protein content in HBM at birth is about 14–16 g/L, but decreases to 8–10 g/L after 3–4 months of birth and further decreases to 7–8 g/L after 6 months [11,15]. The protein concentration of HBM is not significantly affected by maternal diet but increases with maternal body weight for height [14]. In HBM, nonprotein nitrogen is present in about 20%–25% of HBM protein, which is a higher rate than 5% in bovine milk [13,36,39]. Nearly 50% of this is urea nitrogen, which is used to synthesize nonessential amino acids [39].
3) Fat
In HBM, fat is the second largest macronutrient and plays the most important role in the nutrient supply in infants (nearly 50% of the total energy content) and the development of the central nervous system [15]. Colostrum contains 15–20 g/L of fat, but this amount gradually increases, and mature milk contains almost 40 g/L. Its levels are 2–3 times higher in hindmilk than in foremilk [40]. The major component of HBM fatty acid is triglyceride (about 95%–98%), and it also contains 2 essential fatty acids, linoleic acid and alpha-linolenic acid [11]. Linoleic acid and alpha-linolenic acid are precursors of arachidonic acid and eicosapentaenoic acid (EPA) respectively, the latter is further converted to docosahexaenoic acid (DHA), and cannot be synthesized in the human body. In addition, they are important for inflammatory responses, immune function, and growth as components required in the production of in vivo signal transduction and coponents of the nervous system and retina [15]. Fats in HBM are more easily digested and absorbed than those in infant formulas due to the presence of bile salt-stimulated lipases that complement pancreatic lipases and the presence of palmitic acid at the sn-2 position of human milk triglycerides [41]. This positional preference is not well confirmed in infant formulas and affects plasma lipid profile in infants, including cholesterol concentration [25].
Fat content in HBM is closely related to maternal diet and weight gain during pregnancy; in addition, there are regional differences in food intake [15]. The consumption of foods such as breads, snacks, fast foods, and margarines by lactating mothers can cause trans fatty acids to be found in HBM and may account for up to 7.7% of total fatty acids [42]. Trans fatty acid concentrations vary from region to region, and they have adverse effects on infant growth and development and are inversely related to linoleic acid and alpha-linolenic acids [42,43]. Arachidonic acid also correlates with arachidonic acid-rich food intake from lactating mothers, and EPA and DHA are also closely related [44,45]. Therefore, vegetarians have very low levels of DHA in their milk because of the lack of fish or other foods in their diet [46]. Therefore, it is recommended to take up to 300 mg of DHA per day to maintain sufficient amount of DHA in breast milk [47].
2. Vitamins and minerals
Although HBM is influenced by the diet in lactating women, in most cases, it contains enough vitamins to ensure normal growth of the infant [15]. However, vitamins D and K may be insufficient in infants who are exclusively breastfeeding and may require supplementation. Vitamin D is influenced by sun exposure as well as the maternal diet, which is related to climate, season, latitude, skin color, and life style. HBM typically contains less than 1 mg or less than 40 IU/L of vitamin D, which is not sufficient to meet the needs of infants. Breastfed infants can receive vitamin D from HBM synthesized by sunlight exposure in lactating mothers or stored during pregnancy. However, the stored vitamin D is rapidly depleted in infants. The Korean Nutritional Society and American Academy of Pediatrics recommend lactating mothers and infants to take vitamin D supplements of 200–400 IU per day in maintenance doses and 2,000 IU/day in deficiency [48,49]. Vitamin K is also transferred from mother to fetus in limited amounts, so newborn infants can be deficient in vitamin K. Therefore, vitamin K supplementation is recommended after birth [15,50]. Water soluble vitamins are also greatly affected by maternal status [51]. In general, mothers who do not have enough diet may be deficient in vitamins B6, B12, and folate but may still have relatively sufficient thiamin and riboflavin content [51]. More than 20 minerals, including iron, copper, and zinc, have been identified in HBM, most of which are abundant in colostrum and decrease as lactation progresses [52]. Unlike vitamins, most minerals are not significantly affected by the maternal status and do not vary greatly with maternal supplements [13-15,53] (Table 2). The mineral content is lower in HBM than in infant formulas, but due to their high bioavailability, no additional supplementation is required during full breastfeeding. In particular, iron content is 0.5–1.0 mg/L in colostrum and 0.3–0.7 mg/L in mature milk, but its bioavailability is 20%–50%, which is more effective than in infant formula (4%–7%). Therefore, in exclusively breastfed infants, it is generally not necessary to supply iron before 4–6 months of age, and then, it is recommended to supply gradually through iron-enriched solid foods.
3. HBM components in prematurity infants
Premature infants may experience a variety of problems when compared to full-term births. Nutritional attention and sufficient supply are needed because the risk of growth failure, neurodevelopmental delay, sepsis, and gastrointestinal problems, such as necrotizing enterocolitis, is higher [17]. In addition, deficiency-related complications may occur because of the failure to deliver various nutrients that are transferred from the placenta to the fetus during the third trimester [54,55]. Even in this case, HBM plays a primary role as an enteral diet. However, HBM in mothers feeding premature infants differs from HBM in mothers feeding term infants. Protein content and bioactive components tend to be richer, with more fat, free amino acids, and sodium in the preterm [17]. However, these components tend to decrease gradually as lactation progresses. Copper and zinc are also higher in the HBM of mothers feeding preterm infants and decrease gradually with lactation, whereas calcium is lower in preterm cases and gradually increases with lactation [56,57]. Most other minerals have comparable levels at preterm and full term. Lactose, which is present in low amounts in colostrum and increases as lactation progresses, is more pronounced in preterm milk [17]. In addition, lactase in the small intestine is not formed and secreted until 32 weeks of gestation, so it is difficult for premature infants born before 32 weeks of gestation to digest breast milk. HMOs vary in the overall content depending on genetic diversity and the content of fucosylated HMOs [58,59]. Differences in the content of bioactive molecules, such as growth factors and lactoferrin, between colostrum and early mature milk are greater between HBM mothers with preterm birth and HBM mothers with full-term birth [17]. Donor milk or fortification can be used to compensate for the lack of mother's own milk for long-term growth and prognosis of preterm infants [17].
4. Hormones and growth factos in HBM
Hormones and growth factors in HBM also serve as various bioactive proteins and peptides [60]. Functions of hormones in HBM, including parathyroid hormone, insulin, leptin, ghrelin, apelin, nesfatin-1, obestatin, and adiponectin, and their effects in infants are not yet well known. Conversely, many growth factors have been studied relatively more and are known to have various effects on the intestinal tract, vasculature, nervous system, and endocrine system [14] (Table 3). Epidermal growth factors play a critical role in intestinal maturation and repair. Their levels in colostrum are 2,000 times higher than in mature milk and decrease with lactation [14,61]. Brain-derived neurotrophic factor and glial cell-line-derived neurotrophic factor act on the enteric nervous system and are necessary for the development of immature intestine in infants [62]. These neuronal growth factors, including ciliary neurotrophic factor, are found in HBM for up to 90 days after birth [63-65]. Among the neuronal growth factors, S100B is higher in mature milk than in colostrum [66]. Insulin-like growth factor (IGF)-1 and IGF-2 are abundant in colostrum and decrease with lactation; their levels are not significantly different between preterm and term milk, except for IGF-binding protein-2 among in the IGF superfamily [67-69]. IGF is taken up in its bioactive form by the intestine and transported to the blood system [70,71]. IGF-1 plays a role in the survival of enterocytes by protecting them against intestinal damage caused by oxidative stress; furthermore, it stimulates erythropoiesis and helps increase hematocrit [70,72]. Vascular endothelial growth factor and its antagonists are thought to help regulate angiogenesis and reduce damage to the retinopathy of prematurity [14,73]. The concentration of vascular endothelial growth factors is higher in colostrum in both preterm and term and lower in preterm milk than in term milk [74]. Erythropoietin plays a primary role in the increase of red blood cells and is thought to help prevent anemia of prematurity [75,76]. It also plays a role in tightening intestinal junctions and may help reduce the risk of necrotizing enterocolitis [76,77]. Adiponectin is found in large amounts in breast milk, which crosses the intestinal barrier and regulates metabolism and inhibits inflammation [78,79].