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Breast milk has been well proven to be the optimal food for infants up to the first six months of age with the World Health Organisation promoting long-term breastfeeding for the better health and cognitive development of newborns1. Breast milk has unique nutritional and nonnutritional benefits that can be partially explained by ‘epigenetics’ although the majority of the underlying biological mechanisms are still unclear2. The term ‘epigenetics’ is defined as the influence of environmental factors such as maternal and neonatal nutrition that can lead to heritable changes in the gene expression and therefore to a new phenotypic trait without however modifying the DNA sequence of the individual. The epigenetic effect has been quoted to modulate the individual adaptation to the environment and to influence the lifelong health by modifying inflammatory molecular pathways and the immune response. The main mechanisms of the epigenetic modifications that have been implicated involve the process of DNA methylation, histone modification, and the effect of non-coding RNA2. The link between early nutrition and the epigenetic effects on later adult life has been described in the literature2,3. It has been reported that the first two years of life is the time period when epigenetic DNA imprinting activity is considered to be the most active3. Early nutrition epigenetic effect has been reported to potentially play a key role in developmental programming and to possibly influence the individual’s susceptibility to the later development of cardiovascular disease, obesity, diabetes, and other chronic conditions2. Recent evidence has shown that some of the epigenetic changes ensuing from early nutrition can be transgenerationally inherited, thus having a significant impact on the process of evolution2. There are several reports on the epigenetic effects of the contents of breast milk on the health of the newborns. It has been found that oligosaccharides contained in human milk promote a healthier composition of the infant’s gut microbiota, and therefore play a leading role in programming the infant’s immune phenotype and as a result preventing diseases in early and later life4. It has also been reported that breastfeeding, even for a short period of time, may counterbalance the risk of obesity even in genetically predisposed adolescents by inducing epigenetic modifications5. Other studies have shown that the docosahexaenoic acid (DHA) content of human milk is associated with better cognitive development of infants and children6-7. DHA is an important component of the retinal photoreceptors and of the brain cell membranes and hence represents a significant factor for the visual and cognitive development of the individual8. Since the DHA status in infancy may fundamentally impact on long-term health, the European Food Safety Authority has acknowledged this epigenetic effect and has recommended an intake of 100 mg/day of DHA for infants and young children up to the age of 24 months old9. There is a growing body of evidence in the literature supporting that maternal diet can affect the composition of human milk and specifically its fat, fatty acid and vitamin content10. Fat has been proven to be a critical component of breast milk by providing energy and important nutrients that are fundamental to the development of the central nervous system and cannot be synthesized de novo by the infant11. A meta-analysis of 65 studies worldwide found that DHA is the component of human milk that varies greatly among populations12. The meta-analysis reported that the highest DHA concentrations were primarily in coastal populations and were associated with high marine food consumption. AFFILIATION 1 Department of Midwifery, Midwifery School, ‘Alexander’ Technological Educational Institute of Thessaloniki, Greece

The epigenetic effects of breast milk and the association of its nutritional content with maternal diet. Implications for midwifery practice