American Journal of Obstetrics and Gynecology (2006) 194, 93745

www.ajog.org

REVIEW ARTICLE

Calcium supplementation during pregnancy and lactation:

Effects on the mother and the fetus
Michael Thomas, MD,a Steven M. Weisman, PhDb,*
Department of Obstetrics and GynecologyReproductive Endocrinology/Infertility, University of Cincinnati,
Cincinnati, OH a; Innovative Science Solutions, Morristown, NJ b
Received for publication February 18, 2005; revised April 11, 2005; accepted May 5, 2005

KEY WORDS
Calcium
Pregnancy
Lactation
Fetal

Calcium consumption is essential for bone development and maintenance throughout life, yet
more than one half of the female population in the United States does not consume the
recommended amount of calcium. Calcium intake is especially crucial during pregnancy and
lactation because of the potential adverse effect on maternal bone health if maternal calcium
stores are depleted. There is often a transient lowered bone mineral density and increased rate of
bone resorption, with the greatest consequence during the third trimester and throughout
lactation. Studies indicate that calcium consumption should be encouraged, especially during
pregnancy and lactation, to replace maternal skeletal calcium stores that are depleted during these
periods. Because the fetus in utero and the neonate through breast-feeding are dependent on
maternal sources for the total calcium load, adequate maternal calcium intake also can affect fetal
bone health positively. Proper calcium consumption can be attained through the diet by the
consumption of dairy products or leafy greens (such as kale), the consumption of fortified foods,
or by supplementation with widely available calcium-containing supplement products. Because
many women experience heartburn during pregnancy, calcium-based antacids are ideal for
providing heartburn relief, and they offer a calcium supplement to ensure maternal and fetal bone
health, without the danger of adverse effects on the neonate.
2006 Mosby, Inc. All rights reserved.

Calcium is a critical component of human bone and

contributes 1% to 2% of body mass.1 Calcium is
necessary for numerous physiologic functions. Because
calcium cannot be manufactured within the body, all
needed calcium must be consumed dietarily through the
gastrointestinal tract, after which it is transferred to the
skeletal system, where 98% of the calcium is stored.2 In
addition to contributing to skeletal strength, calcium
* Reprint requests: Steven M. Weisman, PhD, 67 Park Place East,
Morristown, NJ 07960.
E-mail: weisman@innovativescience.net
0002-9378/$ - see front matter 2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.05.032

stores are concentrated in teeth and bone serve as

reservoirs for a variety of physiologic functions during
periods of decreased calcium consumption or increased
calcium mobilization. As such, when insucient calcium
is consumed to meet these needs, depletion of calcium
stores in the bone can weaken the skeletal system.3 Bone
is in a dynamic constructive and destructive balance.
This is relevant to both the young and old when this
equilibrium is compromised by the stress of gaining or
losing bone mass. Increased calcium intake is well-recognized as necessary in perimenopausal women to reduce
skeletal weakening and is associated with a decreased

938
Table I

Thomas and Weisman

Dietary calcium sources

Food source
Low-fat plain yogurt
Low-fat yogurt with fruit
Sardines
Cheddar cheese, shredded
Skim milk
2% Low-fat milk
Whole milk
Buttermilk
Mozzarella, part skim
Tofu, firm
Orange juice, calcium
fortified
Salmon with bones
Pudding, chocolate w/2%
milk
Cottage cheese 1% milk fat
Tofu, soft
Spinach, cooked
Frozen yogurt, vanilla,
soft serve
Turnip greens, boiled
Kale, cooked
Kale, raw
Ice cream, vanilla
Bread, white
Broccoli, raw

Table II

Serving
size (oz)

Calcium content
per serving (mg)

8
8
3
1.5
8
8
8
8
1.5
4
6

415
245-384
324
306
302
297
291
285
275
205
200-260

3
4

181
153

8
4
4
4

138
138
120
103

4
8
8
4
1
4

99
94
90
85
31
21

Adapted from the Office of Dietary Supplements, 2004. Available at:

http://ods.od.nih.gov/factsheets/calcium.asp.

fracture risk, which is a consequence of osteopenia and

osteoporosis.4,5 An inverse correlation also exists between
calcium consumption and other ailments, which include
colon cancer,6 thereby making calcium intake important
beyond bone health at all stages of life.
The benets of calcium are well-recognized by the
general public. However, turning this high awareness
into action has proved dicult, which is exemplied by
the fact that less than one half of the female population
meets the recommended intake. In fact, studies show
that only 16% of women consume the minimum 2
recommended servings of dairy each day (Table I).7
Ironically, 63.5% of adults who believe that they consume the correct amount of calcium actually consume
less than the recommended daily levels,8 which suggests
that education regarding an individuals calcium state
would be benecial. Furthermore, at no stage in a
womans life are the recommended intake levels for
calcium achieved.9 As a result, there are important
implications during particular life stages (eg, pregnancy,
lactation, and menopause).
Important points at which calcium intake is critical
are pregnancy and nursing. During pregnancy, the
growing fetus receives its total nourishment from maternal sources.1 The dynamic balance between skeletal

Calcium Recommendations for Women

Age (years)

Adequate
Daily intakes
(mg/day)

Mean
Daily intake
(mg/day)

14-18
19-39

1300
1000

793
797

Adapted from the DRI reports at the USDA Food and Nutrition
Information Center, 2004 and Ervin, 2004.

calcium storage and fetal nutritional needs can aect the

maternal calcium equilibrium adversely. Therefore, if
adequate bone has not been built before pregnancy and
adequate calcium is not part of the maternal diet, bone
can be degraded as calcium is taken from the maternal
skeleton.
This maternal calcium decit during pregnancy and
lactation greatly depletes maternal calcium stores as the
fetus accumulates 25 to 30 g of calcium over the course
of pregnancy.10 The greatest maternal-fetal calcium
transfer occurs during the third trimester.11 At 20 weeks
of gestation, the fetal calcium accretion rate is 50 mg/d
and increases to 330 mg/d at 35 weeks.2 During the
postpartum period, a large amount of calcium is transferred to the neonate through nursing, which accounts
for approximately 210 mg/d.1 Fetal calcium needs are
met through the extraction of calcium from maternal
bone mass, increased intestinal absorption, or decreased
renal excretion.12
To meet this increased skeletal stress, the Institute of
Medicine currently recommends 1000 mg/d of calcium
for pregnant and lactating women who are 19 to 50
years old and 1300 mg/d for pregnant and lactating
women who are !19 years old.1 The failure to meet
this guideline is highlighted by the fact that only 6% of
childbearing women report consuming the recommended daily amount of calcium,13 with actual daily
intakes near 50% to 70% of the recommended intake
(Table II).14-16
According to the Women Physicians Health Study,
47% of the 87 pregnant female physicians consumed
calcium-containing supplements, compared with only
29% of 1148 nonpregnant 30- to 40-year-old physicians
who were surveyed. Also, 36% of the 30- to 40-year-old
pregnant physicians averaged O1 calcium supplement
each day; only 15% of the 30- to 40-year-old nonpregnant physicians used them with the same frequency.17
Physicians personal health practices are of particular
interest because they aect their patient care. A direct
relationship exists between physicians personal health
behaviors and their ability to motivate patients.18 Also,
physicians who practice a certain behavior, such as
calcium supplementation use, are more likely to speak to
their patients about the behavior, which increases compliance and awareness.19

Thomas and Weisman

Dietary calcium is found primarily in dairy foods.
Although milk is the most commonly consumed dairy
product, the national consumption of milk has decreased drastically over the last century,20 with detrimental consequences for the nations overall calcium
levels. Based on the decit in calcium intake from food
sources, other options for ensuring adequate intake are
necessary. Calcium supplements are a viable source of
calcium that can be used to augment often insucient
dietary calcium intakes. Potential calcium sources, often
unrecognized by women, include calcium-containing
antacids, which are used routinely by women to treat
heartburn symptoms that are associated with pregnancy.
Calcium-based antacids come in a variety of forms
that use dierent salts; the 2 most common salts are
calcium carbonate and calcium citrate. Comparative
studies of the absorbability of these 2 salts have shown
calcium carbonate and calcium citrate to be equally well
absorbed when taken with food, with further investigation demonstrating that calcium carbonate and calcium
citrate provide bioavailable calcium equally as well
as dietary sources such as milk and calcium-fortied
orange juice. Although, because calcium carbonate
supplements have the highest percentage of elemental
calcium among the calcium salts, they are generally
considered the most cost-eective form and should be
the rst choice for most patients. In addition, because
calcium carbonate has approximately twice as much
elemental calcium as calcium citrate, it requires fewer
tablets to achieve a given dose of elemental calcium,
which results in a decreased cost for the patient and a
potentially increased rate of patient compliance.
Previous review articles have been published regarding maternal calcium requirements during pregnancy
and lactation and have concluded that the lack of
available evidence restricts the ability to form strong
conclusions, especially with respect to supplementations
eect on maternal bone health during pregnancy.2,21,22
Yet, more recently published studies urge a re-evaluation
of the evidence.14,23 In this re-evaluation, data are
presented to support the theory that, to protect against
loss of bone mass, calcium intake should be supplemented through diet or other means to attain or exceed
the recommended intake values during the reproductive
period. In addition to ensuring optimal maternal bone
health, increased calcium intake should increase the
amount of calcium that is available to the fetus during
pregnancy and the infant while breast-feeding.

Evidence for bone loss during pregnancy

and lactation
Numerous studies have demonstrated signicant decreases in bone mineral indicators in pregnant and

939
lactating women, with the greatest change occurring
during the third trimester and lactation. These are the
periods when the greatest maternal-fetal calcium transfer takes place.10,24,25 Measurements of bone health are
provided as bone mineral density (BMD) value, which is
a measurement of the density of the bone in grams per
cubic centimeter, or bone mineral content (BMC), which
is a measurement of the mass of the bone in grams.
Reductions in total BMD values up to 3.6% have been
detected.26 Decreases at the lumbar region have been
observed, as well as at the hip, femoral neck, ultradistal
radius, and trochanter. In a study by Pearson et al,27
O5% of bone mass can be lost at the spine, sometimes
reaching 7%. Another study demonstrated that markers
of bone turnover are increased greatly during pregnancy, which indicates an increase in bone resorption
and a decline in bone health.28 Although some of the
bone mass that is lost during lactation is regained after
weaning, the bone mass only partially returns to
prepregnancy values. The rate of bone loss during
pregnancy and lactation is greater than the annual rate
of loss in women after menopause.21 Therefore, adequate calcium consumption is vital, especially for pregnant and lactating women.

Impact of increased calcium intake

Studies have indicated that an increased calcium intake
reduces, and in some cases counteracts, the reduction of
maternal bone during pregnancy and lactation. We will
summarize a number of studies that examine maternal
and fetal bone health as a function of calcium intake,
either through dietary means or a calcium supplement,
through pregnancy, lactation, and weaning.
Based on the fact that physiologic demands are
dierent for each of these stages, each stage has been
evaluated separately. In lactation and weaning studies,
we evaluate studies of the eects of an increased intake
of dietary calcium, a study that incorporated both
dietary and supplemental calcium, and studies that
involved only calcium supplements. The evidence indicates that the benecial eects of calcium can be
obtained equally from both diet and supplementation.

Pregnancy
A wealth of information exists to indicate that increased
calcium intake and calcium supplementation improves
bone health throughout the lifespan.29-31 Yet, there are
limited studies regarding the eect of supplementation
during pregnancy because of medical/legal/ethical concerns (Table III). Janakiraman et al23 published 1 of the
rst papers to examine the eect of calcium supplementation during pregnancy on the rates of maternal bone
resorption.

940
Table III

Thomas and Weisman

Maternal studies

Study

Calcium source/dosage

Outcomes

Janakiraman, 200323

Population

1200 mg/day supplement

14% decrease NTX

Cross, 199534

1 g/day calcium carbonate

supplement

5.7% BMD gain at ultradistal

site in calcium group

1 g/day calcium carbonate

supplement

3% BMD gain at lumbar region in

calcium group, no statistical
gain in placebo group
5.2% BMD loss at ultradistal site
in placebo, no statistical loss
in calcium group
Significant positive effect of
calcium supplementation on
the lumbar spine region BMD

31 pregnant Mexican
women, 25 to 35
weeks gestation
Baseline to
15 lactating women,
lactation
2 weeks postpartum
to 3 months lactation
Lactation to
15 lactating women, 3
postweaning
months lactation to
3 months post-weaning

Kalkwarf, 199764 Lactation study 97 lactating women, 99

non-lactating women,
2 weeks to 6 months
postpartum
Weaning study 95 lactating women, 92
non-lactating women,
6 to 12 months
postpartum
Chan, 198733
21 experimental pregnant
adolescents, 15 control
pregnant adolescents, 12
adults, 1 month pre-partum
to 16 weeks postpartum
Krebs, 199732
26 lactating women, 8
non-lactating women, 0.5
months to 7 months
postpartum

This study evaluated the eect of a 1200 mg/d

calcium supplement in 31 pregnant Mexican women in
their third trimester (25-35 weeks of gestation) for the
eect on the bone resorption marker of cross-linked
N-telopeptides of type I collagen.23 In this crossover
study, subjects in 1 experimental group ingested the
calcium supplement for 10 consecutive days and then a
multivitamin without calcium for another 10 consecutive days. Nearly 90% of the women showed an average
reduction of 14% in N-telopeptides of type I collagen
level during the period of calcium supplementation,
which indicates that there is a lower rate of bone
resorption during the last trimester of pregnancy in
those women who receive a calcium-containing supplement than those women without supplementation.

Lactation
One study examined BMD values as a function of
dietary calcium intake, which demonstrated evidence for
the benets of calcium during lactation.32 Twenty-six
lactating women and 8 nonlactating women were observed for the eect of dietary calcium intake on maternal
BMD values from delivery until 7 months after delivery. In

1 g/day calcium carbonate

supplement

1 g/day calcium carbonate

supplement

Lumbar spine BMD increased

significantly more in the
calcium group than the
placebo group
Control adolescent group
Dietary calcium decreased BMC 10%, no
Experimental: O1600 mg/day
statistical decrease in
Control: 900 mg/day
high-calcium group
Adult: 1500 mg/day
Dietary calcium

High calcium intake positively

associated with lumbar BMD

the lactating women, dietary calcium intake ranged from

1335 to 1500 mg/d, which is far above the recommended
intake values. Based on regression analyses, calcium intake
was the only variable among all tested nutrients that was
found to be associated positively with BMD values.
Throughout the study, calcium intake was associated
signicantly with increased lumbar spine BMD values.
In a study of lactating adolescent women, calcium
intake and BMC showed a signicant positive correlation.33 From the last month of pregnancy through 16
weeks after delivery, 21 adolescents consumed a high
calcium diet of O1600 mg/d; their results were compared with results for adolescents who consumed their
regular diet of 900 mg/d of calcium and adults who
consumed 1500 mg/d of calcium. Some individuals in
the study used calcium supplements to achieve the target
calcium intake of 1600 mg/d. By the end of the trial,
the adolescent control group showed a 10% loss in
BMC, although the high-calcium diet group showed no
decrease in BMC. Bone demineralization occurred only
in the adolescent control group. No dierence was
perceived between those women who relied on dietary
calcium only and those women who augmented their
diet with a calcium supplement, which suggests that

Thomas and Weisman

Table IV

941

Fetal/neonatal studies

Study

Population

Koo, 199936

256 maternal/neonatal pairs, 22 2 g/day calcium carbonate

weeks gestation to delivery
supplement

Calcium source/dosage

Outcomes

Increased total-body and lumbar BMC in infant

correlated with increased total maternal
calcium intake
Raman, 197837
87 maternal/neonatal pairs, 20 Group 1: no supplement
Maternal BMD increase in 4th metacarpal
weeks gestation to delivery
in Group 3
Group 2: 300 mg/day calcium Neonatal BMD higher at ulna, radius, tibia,
lactate supplement
and fibula in Groups 2 & 3 than Group 1
Group 3: 600 mg/day calcium Highest neonatal fibula BMD in Group 3
lactate supplement
Positive correlation between maternal dairy
Chang, 200314
350 African-American maternal/ Dietary calcium (dairy)
intake and fetal femur length
neonatal pairs, 20-34 weeks
Half of population consumed !600mg/day
gestation to 42 weeks
postpartum
Krishnamachari and 15 maternal/neonatal pairs from
Neonatal BMD at radius, ulna, tibia, and fibula
Iyengar, 197538
high socioeconomic group, 21 Dietary calcium
higher in high socioeconomic group than
maternal/neonatal pairs from
low socioeconomic group
low socioeconomic group

calcium supplementation is a reasonable alternative to

the achievement of an adequate dietary calcium intake.
A randomized trial evaluated the eects of a 1000-mg
calcium carbonate supplement on maternal BMD values
in lactating women (within 2 weeks after delivery and at
3 months of lactation) and demonstrated less loss of
bone mass in the calcium supplement group.34 During
lactation, a 5.7% gain at the ultradistal radius was
observed for the calcium group. This study also included
an examination of the weaning/post-weaning period.
The eect of a 1000-mg/d calcium carbonate supplement on postpartum women who consumed %800 mg
of dietary calcium daily was evaluated in 2 studies;
1 study examined the eect of the supplement on
lactating women.35 In the lactation study, calcium
supplementation had an overall signicant positive
eect on lumbar BMD values. The lactating women
who received the calcium supplement only lost 2.4% of
their total-body bone mass; the women who received the
placebo lost 3.4% of their total-body bone mass.

Postweaning phase
In the postweaning phase, Cross et al34 demonstrated
the benecial eects of calcium carbonate supplementation. The calcium group signicantly increased BMD
values at the lumbar region 3%; the placebo groups
increase did not reach statistical signicance. Signicant
mean losses of 5.2% were seen at the ultradistal radius
in the placebo group. For the entire trial period (baseline
through postweaning), the only statistically signicant
loss was at the ultradistal site in the placebo group, not
in the calcium group.
In the weaning component of the study by Kalkwarf
et al,35 signicant increases in lumbar BMD values were

observed, independent of calcium carbonate supplementation. This supports the theory that bone mass is lost
during lactation but is regained after weaning occurs.
However, the group that received the calcium supplement increased lumbar bone density signicantly more
than the placebo group. Although bone mass is regained
after weaning occurs whether or not a calcium supplement is ingested, the increase in bone density is much
greater with the use of a calcium supplement.

Fetal bone health

Studies have been undertaken to examine maternal
calcium intake, especially increased intake through supplementation, and its eect on fetal skeletal development, with particular attention paid to fetal BMD
values and content (Table IV).
Pregnant women at 22 weeks of gestation consumed a
2-g calcium carbonate supplement or a placebo daily to
test the eects of supplementation on fetal BMC.36 For all
subjects, there was a signicant trend that indicated a positive association between total maternal calcium intake
and mean total-body BMC and lumbar spine BMC in
the fetus. Comparisons between the calcium and placebo
groups demonstrated that neonates in the calcium group
had a higher total-body BMC and lumbar spine BMC
than those neonates in the group without supplementation. Essentially, this study concluded that a maternal
calcium supplementation of approximately 1300 mg daily
can enhance fetal bone mineralization in women with low
calcium intakes, even in auent countries.36
Raman et al37 evaluated the eect of dierent
strengths of a calcium supplement in 87 pregnant
women from 20 weeks of gestation until delivery. The
bone density of the neonates was tested to determine the

942
eect of supplementation with 300-mg/d calcium lactate,
600-mg/d calcium lactate, or placebo. For both supplementation groups, a statistically higher neonatal BMD
value was observed at all sites that were tested (ulna,
radius, tibia, and bula) compared with placebo. The
only statistically signicant dierence between the 600mg/d group and the 300-mg/d group appeared in an
analysis of the bula maternal BMD values. This study
demonstrates that calcium supplementation in pregnant
women results in an increased initial bone density of the
neonate that is essential because bone density progressively increases with age, building on the initial levels.37
Fetal femur length was examined as a function of
maternal dairy consumption in a study of 350 pregnant
black adolescents.14 Dietary calcium intakes were divided by servings that were estimated to be approximately 300 mg each. One half of the study population
consumed !600 mg/d, which is !50% of the recommended intake. A strong positive correlation between
maternal dairy intake and fetal femur length, as determined by ultrasound examination, was observed. Although a high dairy intake was associated with an
overall improved nutritional intake, nutrients other than
calcium were found not to be confounding variables in
the determination of fetal femur length, which suggests
that a calcium supplement would provide comparable
benets to diet alone.
Although it is important to note that data from
developing nations should be interpreted with caution,
because they may not be applicable necessarily to the
western populations. Data from studies that were
conducted in India and Gambia are included for
completeness. As such, in a study in India, maternal
malnutrition, which included calcium deciency and its
eect on fetal BMD values, was evaluated by comparing
pregnant women of high and low socioeconomic communities, which was dened by their income.38 Women
in the upper socioeconomic group consumed 700 to 800
mg/d calcium, although members of the low socioeconomic group consumed only 300 mg/d calcium. Fetal
BMD values at the radius, ulna, tibia, and bula were
signicantly higher in the upper socioeconomic group
than in the low socioeconomic group. Maternal BMD
values followed a similar trend, with an increased BMD
value in the high socioeconomic group compared with
the low socioeconomic group at all sites.
Another study that included women in Gambia has
results that contrast with the previously cited studies in
that they conclude that maternal bone changes during
lactation are independent of calcium supplementation.12,39-41 Other studies have come to similar conclusions that eliminate maternal calcium intake as a
predictor of bone density. Knowledge of calcium as a
threshold nutrient, in that a certain amount of the
nutrient is used and all excess is excreted, also raises the
question of the ecacy of extreme supplementation.

Thomas and Weisman

Some studies that detect a negative change in BMD
values, despite supplementation, are based on subjects
who consumed more than the recommended amount of
calcium at baseline examinations.40 Many studies also
observed that the BMD values that were lost during
pregnancy and that lactation is regained by the resumption of menses independent of calcium intake42; however, BMD value increase does not always restore BMD
values to the level before pregnancy. The bone responds
to other stresses throughout the lifespan by depleting
bone mass and that loss and this loss can be countered
by increased calcium consumption. It is a logical conclusion, which is supported by available literature, that a
similar increase in calcium consumption during pregnancy and lactation would reduce the loss of bone mass
during these specic periods.

Heartburn symptom relief

Because many women experience heartburn during their
pregnancy, calcium-based antacids (such as calcium
carbonate) can be used both for heartburn relief and
as a calcium supplement to provide bone health benets.
Antacids are the preferred rst-line defense for treating
heartburn symptoms. They are used by 30% to 50% of
pregnant women to control heartburn symptoms and
are available in a variety of forms.43 Calcium antacids
are safe for use during pregnancy and result in an 80%
improvement in symptoms.44,45 Animal studies have not
found any adverse eects from exposure to high doses of
calcium carbonate before mating and during pregnancy,46 nor have teratogenic eects been observed in
human cases.47
Nearly 25% of the women who were surveyed consumed O10% of the daily calcium requirement from
calcium-containing antacids.15 Between 45% and 85% of
pregnant women experience heartburn symptoms, and
many of them use over-the-counter medications that are
convenient and easy to use to abate the symptoms.48 A
study of 607 pregnant women found that the prevalence
and severity of heartburn, which aicted 72% of the
subjects by the third trimester, increased with gestational
age.49 The physical discomfort that was experienced by
women with heartburn symptoms can negatively impact
the nutritional quality of maternal diets, including calcium intake. Calcium-containing antacids are a valuable
calcium source for those with a calcium decit by providing a vehicle through which many can remedy their
insucient dietary calcium intake.
The most common mechanism of heartburn relief is
acid reduction; however, recently, chewable calciumbased antacids have been shown to improve lower
esophageal sphincter pressure for O30 minutes, which
can aid in heartburn relief.50 In addition, the calciumbased antacids improved the initiation of peristalsis and
acid clearance.51 These ndings suggest that calcium, in

Thomas and Weisman

the form of calcium carbonate, may play a pivotal role
in smooth muscle function, which is essential during
pregnancy to prevent symptoms and provide relief of
heartburn.51
On the basis of its benets in reducing heartburn
symptoms while contributing to maternal and fetal
calcium stores, calcium carbonate antacids are both
ideal and safe for use by pregnant women.

Comment
Calcium is an essential nutrient during pregnancy and
lactation that supports the growth and development of
the fetus, especially because of its maternal-fetal transfer.
Pregnancy places a signicant demand on calcium, in
that the dynamic balance of calcium storage is upset, and
calcium is drawn from the maternal skeleton. Because
most pregnant women do not consume the recommended
quantity of calcium at any time in their lives, including
the critical pregnancy and lactation periods, supplementation should be recommended to restore the balance.
Studies indicate that increases in calcium intake during pregnancy and lactation improve maternal bone
health while also providing a larger source of calcium
to the fetus. Adequate calcium consumption can replace
lost maternal bone mass, reduce bone resorption, and, in
some cases, reverse bone loss so that bone mass is gained.
Calcium supplementation during pregnancy can be
linked directly to increased bone density and bone length
of neonates.
In addition to maternal and fetal skeletal benets of
calcium supplementation, many other advantages have
been linked to adequate calcium intake. Maternal health
is maintained with a reduced risk of pregnancy-induced
hypertension52-54 and a decrease in circulating lead.55,56
Again, because of the exchange of maternal and fetal
nutrients, numerous other benets to fetal health have
been observed. Higher birth weight babies,53,57 a reduced
risk of preterm delivery,52,53,58 decreased fetal lead exposure,55,58 and lower infant blood pressure53,59,60 have all
been linked with a high calcium intake during pregnancy.
Also, it has been shown that calcium supplementation
during pregnancy can reduce the incidence of preeclampsia. These reduced rates of preeclampsia (a serious
condition with maternal and fetal complications) also
have been associated with proper calcium consumption
in women with low calcium intake. This condition is a
major cause of maternal morbidity and death and a
contributor to preterm delivery, intrauterine growth
restriction, and perinatal death.61 Calcium consumption
during pregnancy can lead to a 45% to 75% reduction in
the incidence of preeclampsia.57 In the National Institutes of Health trial entitled Calcium for the Prevention
of Preeclampsia, patients received 2000 mg of calcium
carbonate daily; preeclampsia was seen in 6.9% of the
calcium group as compared with 7.3% of the placebo

943
group.62 Other studies have seen similar and more
substantial preeclampsia-lowering eects of calcium in
doses that range from 1000 mg to 2000 mg daily.52,63
Although most of the data suggest a benecial eect of
calcium supplementation, the variation between studies
regarding locations of measurements, reporting methods,
and small sample sizes in some studies would make a
quantitative comparison of the data extremely complex.
Similarly, in many of the studies, improvements in bone
health were not universal for all tested bone sites.
Although the benecial eects were not perceived at all
sites, the overall trend indicates a positive correlation
between calcium supplementation and bone health. Different studies use a variety of reporting methods, such as
BMD scans, calculations of BMC, ultrasound examinations, and collagen and hormonal levels. Ethical restrictions on clinical trials regarding supplementation during
pregnancy reduce the availability of studies.
Pregnant women who consume low-calcium diets have
the most to gain from a calcium supplement as they enter
a period of calcium imbalance with an already depleted
skeleton, which leads to the extraction of calcium from
maternal stores to meet fetal developmental needs.22 An
ecient method of obtaining this increased calcium load
is through calcium-containing antacids, which provide
the dual benets of short-term heartburn symptom relief
and long-term preservation and/or creation of maternal
and fetal bone mass. Based on the studies that we
examined, increased calcium intake during pregnancy
and lactation, especially through supplementation, can
result in meaningful public health improvements that
benet both maternal and fetal skeletal health.

References
1. Institute of Medicine. DRI dietary reference intakes for calcium,
phosphorus, magnesium, vitamin D, and uoride. Washington
(DC): National Academy Press; 1997.
2. Prentice A. Calcium in pregnancy and lactation. Annu Rev Nutr
2000;20:249-72.
3. Heaney RP. Calcium, dairy products and osteoporosis. J Am Coll
Nutr 2000;19(suppl):83S-99S.
4. Tresolini CP, Gold DT, Lee LS. Working with patients to prevent,
treat, and manage osteoporosis: a curriculum guide for the health
professions. 3 ed. San Francisco, CA: National Fund for Medical
Education; 2001.
5. US Department of Health and Human Services. Report of the
Surgeon Generals workshop on osteoporosis and bone health
(web page); posted December 2002; last accessed June 28, 2004.
Available at: http://www.surgeongeneral.gov/library/bonehealth/
content.html.
6. Wallace K, Baron JA, Cole BF, Sandler RS, Karagas MR, Beach
MA, et al. Eect of calcium supplementation on the risk of large
bowel polyps. J Natl Cancer Inst 2004;96:921-5.
7. US Department of Health and Human Services, Health Resources
and Services Administration Maternal and Child Health Bureau.
Womens health USA 2003. Rockville (MD): US Department of
Health and Human Services; 2003.
8. US Department of Agriculture, Agricultural Research Service.
Results from USDAs 1994-1996 diet and health knowledge

944

9.

10.

11.
12.

13.

14.

15.

16.

17.

18.

19.

20.

21.
22.
23.

24.

25.

26.
27.

28.

survey: table set 19 (web page); posted October 2000; last accessed
July 8, 2004. Available at: http://www.barc.usda.gov/bhnrc/
foodsurvey/home.htm.
Ervin RB, Wang CY, Wright JD, Kennedy-Stephenson J. Dietary
intake of selected minerals for the United States population: 19992000: advance data from vital and health statistics; no. 341.
Hyattsville (MD): National Center for Health Statistics; 2004.
Drinkwater BL, Chesnut CH 3rd. Bone density changes during
pregnancy and lactation in active women: a longitudinal study.
Bone Miner 1991;14:153-60.
Givens MH, Macy IG. The chemical composition of the human
fetus. J Biol Chem 1933;102:7-17.
Prentice A, Jarjou LM, Cole TJ, Stirling DM, Dibba B, Fairweather-Tait S. Calcium requirements of lactating Gambian
mothers: eects of a calcium supplement on breast-milk calcium
concentration, maternal bone mineral content, and urinary calcium excretion. Am J Clin Nutr 1995;62:58-67.
March of Dimes Birth Defect Foundation. During your pregnancy:
do you get enough calcium every day? (web page). Accessed July 8,
2004. Available at: http://www.marchofdimes.com.
Chang SC, OBrien KO, Nathanson MS, Cauleld LE, Mancini J,
Witter FR. Fetal femur length is inuenced by maternal dairy
intake in pregnant African American adolescents. Am J Clin Nutr
2003;77:1248-54.
Harville EW, Schramm M, Watt-Morse M, Chantala K, Anderson
JJ, Hertz-Picciotto I. Calcium intake during pregnancy among
white and African-American pregnant women in the United States.
J Am Coll Nutr 2004;23:43-50.
US Department of Agriculture, Center for Nutrition Policy and
Promotion. Federal Studies. Review of the nutritional status of
WIC participants. Fam Econ Nutr Rev 2001;13:118-9.
Frank E, Cone K. Characteristics of pregnant vs. non-pregnant
women physicians: ndings from the women physicians health
study. Int J Gynaecol Obstet 2000;69:37-46.
Frank E, Breyan J, Elon L. Physician disclosure of healthy
personal behaviors improves credibility and ability to motivate.
Arch Fam Med 2000;9:287-90.
Frank E, Rothenberg R, Lewis C, Belodo BF. Correlates of
physicians prevention-related practices: ndings from the Women
Physicians Health study. Arch Fam Med 2000;9:359-67.
Putnam JJ, Allshouse JE. Food consumption, prices, and expenditures, 1970-97: statistical bulletin no. 965. Washington (DC):
Food and Rural Economics Division, Economic Research Service,
US Department of Agriculture; 1999.
Kalkwarf HJ, Specker BL. Bone mineral changes during pregnancy and lactation. Endocrine 2002;17:49-53.
Prentice A. Maternal calcium metabolism and bone mineral status.
Am J Clin Nutr 2000;71(suppl):1312S-6S.
Janakiraman V, Ettinger A, Mercado-Garcia A, Hu H, HernandezAvila M. Calcium supplements and bone resorption in pregnancy:
a randomized crossover trial. Am J Prev Med 2003;24:260-4.
Anito P, Tommaselli GA, di Carlo C, Guida F, Nappi C.
Changes in bone mineral density and calcium metabolism in
breastfeeding women: a one year follow-up study. J Clin Endocrinol Metab 1996;81:2314-8.
Kent GN, Price RI, Gutteridge DH, Allen JR, Rosman KJ, Smith
M. Eect of pregnancy and lactation on maternal bone mass and
calcium metabolism. Osteoporos Int 1993;3(suppl):44-7.
Sowers MF, Scholl T, Harris L, Jannausch M. Bone loss in adolescent and adult pregnant women. Obstet Gynecol 2000;96:189-93.
Pearson D, Kaur M, San P, Lawson N, Baker P, Hosking D.
Recovery of pregnancy mediated bone loss during lactation. Bone
2004;34:570-8.
Naylor KE, Iqbal P, Fledelius C, Fraser RB, Eastell R. The eect
of pregnancy on bone density and bone turnover. J Bone Miner
Res 2000;15:129-37.

Thomas and Weisman

29. Aloia JF, Vaswani A, Yeh JK, Ross PL, Flaster E, Dilmanian FA.
Calcium supplementation with and without hormone replacement
therapy to prevent postmenopausal bone loss. Ann Intern Med
1994;120:97-103.
30. Fujita T, Ohue T, Fujii Y, Miyauchi A, Takagi Y. Eect of
calcium supplementation on bone density and parathyroid
function in elderly subjects. Miner Electrolyte Metab 1995;21:
229-31.
31. Ginty F, Flynn A, Cashman KD. The eect of short-term calcium
supplementation on biochemical markers of bone metabolism in
healthy young adults. Br J Nutr 1998;80:437-43.
32. Krebs NF, Reidinger CJ, Robertson AD, Brenner M. Bone
mineral density changes during lactation: maternal, dietary, and
biochemical correlates. Am J Clin Nutr 1997;65:1738-46.
33. Chan GM, McMurry M, Westover K, Engelbert-Fenton K,
Thomas MR. Eects of increased dietary calcium intake upon
the calcium and bone mineral status of lactating adolescent and
adult women. Am J Clin Nutr 1987;46:319-23.
34. Cross NA, Hillman LS, Allen SH, Krause GF. Changes in bone
mineral density and markers of bone remodeling during lactation
and postweaning in women consuming high amounts of calcium.
J Bone Miner Res 1995;10:1312-20.
35. Kalkwarf HJ, Specker BL, Ho M. Eects of calcium supplementation on calcium homeostasis and bone turnover in lactating
women. J Clin Endocrinol Metab 1999;84:464-70.
36. Koo WW, Walters JC, Esterlitz J, Levine RJ, Bush AJ, Sibai B.
Maternal calcium supplementation and fetal bone mineralization.
Obstet Gynecol 1999;94:577-82.
37. Raman L, Rajalakshmi K, Krishnamachari KA, Sastry JG. Eect
of calcium supplementation to undernourished mothers during
pregnancy on the bone density of the bone density of the neonates.
Am J Clin Nutr 1978;31:466-9.
38. Krishnamachari KA, Iyengar L. Eect of maternal malnutrition
on the bone density of the neonates. Am J Clin Nutr 1975;28:
482-6.
39. Fairweather-Tait S, Prentice A, Heumann KG, Jarjou LM, Stirling
DM, Wharf SG. Eect of calcium supplements and stage of
lactation on the calcium absorption eciency of lactating women
accustomed to low calcium intakes. Am J Clin Nutr 1995;62:
1188-92.
40. Prentice A. Calcium requirements of breast-feeding mothers. Nutr
Rev 1998;56:124-7.
41. Prentice A, Jarjou LM, Stirling DM, Buenstein R, FairweatherTait S. Biochemical markers of calcium and bone metabolism
during 18 months of lactation in Gambian women accustomed to a
low calcium intake and in those consuming a calcium supplement.
J Clin Endocrinol Metab 1998;83:1059-66.
42. Laskey MA, Prentice A, Hanratty LA, Jarjou LM, Dibba B,
Beavan SR. Bone changes after 3 mo of lactation: inuence of
calcium intake, breast-milk output, and vitamin D-receptor genotype. Am J Clin Nutr 1998;67:685-92.
43. Lewis JH, Weingold AB. The use of gastrointestinal drugs
during pregnancy and lactation. Am J Gastroenterol 1985;80:
912-23.
44. Tytgat GN, Heading RC, Muller-Lissner S, Kamm MA, Scholmerich J, Berstad A. Contemporary understanding and management of
reux and constipation in the general population and pregnancy:
a consensus meeting. Aliment Pharmacol Ther 2003;18:291-301.
45. Black RA, Hill DA. Over-the-counter medications in pregnancy.
Am Fam Physician 2003;67:2517-24.
46. Shackelford ME, Collins TF, Welsh JJ, Black TN, Ames MJ, Chi
RK. Foetal development in rats fed AIN-76A diets supplemented
with excess calcium. Food Chem Toxicol 1993;31:953-61.
47. Lilienthal D, Ormond K, Pergament E. Gastroesophageal reux
(GERD) medications in pregnancy. Accessed June 18, 2004.
Available at: http://www.fetal-exposure.org/REFLUX.html.

Thomas and Weisman

48. Broussard CN, Richter JE. Treating gastro-oesophageal reux
disease during pregnancy and lactation: what are the safest therapy
options? Drug Saf 1998;19:325-37.
49. Marrero JM, Goggin PM, de Caestecker JS, Pearce JM,
Maxwell JD. Determinants of pregnancy heartburn. BJOG 1992;
99:731-4.
50. DeVault KR. Gastroesophageal reux disease. Digest Disease
Week 2003: Primary Care Focus. May 18-21, 2003, Orlando, FL.
51. Rodriguez-Stanley S, Ahmed T, Zubaidi S, Riley S, Miner PB Jr.
Luminal calcium from chewable antacids improves esophageal
function. Gastroenterology 2003;124(suppl):A109-10.
52. Carroli G, Duley L, Belizan JM, Villar J. Calcium supplementation during pregnancy: a systematic review of randomised controlled trials. BJOG 1994;101:753-8.
53. Hofmeyr GJ, Roodt A, Atallah AN, Duley L. Calcium supplementation to prevent pre-eclampsiaa systematic review. S Afr
Med J 2003;93:224-8.
54. Villar J, Belizan JM. Same nutrient, dierent hypotheses: disparities in trials of calcium supplementation during pregnancy. Am J
Clin Nutr 2000;71(suppl):1375S-9S.
55. Gulson BL, Mahaey KR, Jameson CW, Mizon KJ, Korsch MJ,
Cameron MA. Mobilization of lead from the skeleton during the
postnatal period is larger than during pregnancy. J Lab Clin Med
1998;131:324-9.
56. Lagerkvist BJ, Ekesrydh S, Englyst V, Nordberg GF, Soderberg
HA, Wiklund DE. Increased blood lead and decreased calcium
levels during pregnancy: a prospective study of Swedish women
living near a smelter. Am J Public Health 1996;86:1247-52.

945
57. Yang CY, Chiu HF, Chang CC, Wu TN, Sung FC. Association of
very low birth weight with calcium levels in drinking water.
Environ Res 2002;89:189-94.
58. Crowther CA, Hiller JE, Pridmore B, Bryce R, Duggan P, Hague
WM. Calcium supplementation in nulliparous women for the
prevention of pregnancy-induced hypertension, preeclampsia and
preterm birth: an Australian randomized trial: FRACOG and the
ACT Study Group. Aust N Z J Obstet Gynaecol 1999;39:12-8.
59. Hatton DC, Harrison-Hohner J, Coste S, Reller M, McCarron D.
Gestational calcium supplementation and blood pressure in the
ospring. Am J Hypertens 2003;16:801-5.
60. Belizan JM, Villar J, Bergel E, del Pino A, Di Fulvio S, Galliano
SV. Long-term eect of calcium supplementation during pregnancy on the blood pressure of ospring: follow up of a
randomised controlled trial. BMJ 1997;315:281-5.
61. Morris CD, Jacobson SL, Anand R, Ewell MG, Hauth JC, Curet
LB, et al. Nutrient intake and hypertensive disorders of pregnancy:
Evidence from a large prospective cohort. Am J Obstet Gynecol
2001;184:643-51.
62. Levine RJ, Hauth JC, Curet LB, Sibai BM, Catalano PM, Morris
CD, et al. Trial of calcium to prevent preeclampsia. N Engl J Med
1997;337:69-76.
63. Hofmeyr GJ, Roodt A, Atallah AN, Duley L. Calcium supplementation to prevent pre-eclampsia: a systematic review. S Afr
Med J 2003;93:224-8.
64. Kalkwarf HJ, Specker BL, Bianchi DC, Ranz J, Ho M. The eect
of calcium supplementation of bone density during lactation after
weaning. N Engl J Med 1997;337:523-8.