This is the response that my colleague sent to the nutrition student who
assessed her 6 1/2 month old breastfed baby as being undernourished.
--------------------
Since I had a scheduled appointment at the pediatrician's office, I
asked that they check Spencer's hemoglobin level. It is 13.0.
Spencer is now seven months old, and still is exclusively breastfed.
He takes no vitamin nor mineral supplements. It appears that he
apparently does not need any iron supplementation. Here is my response to
the nutrition student's assessment of my baby's growth and nutritional status.
October 30, 1997
Dear xxx
Thank you for forwarding your report on the nutritional assessment of
my son, Spencer Koeller. As a mother, I am, of course, interested in
the findings. As a certified Childbirth Educator, an accredited La
Leche League Leader, and the Conference Coordinator of the Vermont
Lactation Consultant Association, I am interested in educating both
parents and professionals who are involved with pregnant and
breastfeeding mothers. I feel it is important that I write to you so
that you may gain a better understanding about the benefits of
breastfeeding. I hope you will pass this knowledge on to others in
your class and when you are working in the field.
Your analysis stated that Spencer is lacking in his Recommended Daily
Allowance for four categories: total calories, calcium, iron, and
zinc.
I found information in your report to be inaccurate when applied to
an exclusively breastfed baby. I believe that much of the
information you relied on to assess Spencer's growth is based on
studies and findings of babies who are primarily fed artificial baby
milk (formula). The belief that breastmilk and artificial baby milk
are essentially the same is simply not true. This is often an
underlying assumption in many studies regarding infant feeding and
nutrition.
The resources I use for information on breastfeeding are primarily
The Breastfeeding Answer Book, revised edition (1997) by La Leche
League International, and Breastfeeding and Human Lactation by Jan
Riordan and Kathleen G. Auerbach. These are both highly respected
and well used resources in the field of lactation. Another good
source is Breastfeeding:Biocultural Perspectives, edited by Patricia
Stuart-Macadam and Katherine A. Dettwyler.
I found the following information on growth in the Breastfeeding
Answer Book (Pages 114-115)
Typical weight gain for the first 3 to 4 months is 4 to 8 ounces
(113 to 227 grams) per week -- doubling birth weight by 5 to 6
months. Weight gain should always be figured from the lowest point
rather than from birth weight.
The very rapid growth a baby experiences during the first 3 months
typically slows down during months 4 to 12. According to recent
research (Cohen 1995: Dewey 1992a), an average weight gain for a
breastfeeding baby 4 to 6 months is about 3 to 5 ounces (85 to 142
grams) per week. An average weight gain for the breastfeeding baby
6 to 12 months is 1 ½ to 3 ounces (42 to 85 grams) per week. Growth
in length averages about one-half inch (1.27 cm) per month and
growth in head circumference is about one-quarter inch (64 mm) per
month. At one year, the typical breastfed baby weighs about 2 ½
times his birth weight, has increased his birth length by 50%, and
his head circumference by 33%.
More recent studies comparing exclusively breastfed and exclusively
formula-fed infants found growth in length and head circumference to
be about the same in both groups but found significant difference in
energy consumption and weight gain after 3 months of age. From the
fourth month to the twelfth month the breastfed babies gained more
slowly, even after solids were started, and at one year the
breastfed babies were leaner than the artificially fed babies. The
amount of milk consumed during this period by the breastfed babies
was also about 20% less than that consumed by the artificially fed
babies. Yet the breastfed babies were healthy, active, and
thriving. The authors concluded that current growth charts do not
accurately reflect the norm for breastfed babies and that new growth
charts are needed. (My emphasis)
Based on this research, Spencer is within normal limits. He weighed
8 pounds on March 23, the day after his birth (the lowest recorded
weight), and he weighed 17 pounds at six months (9/26/97). He has
doubled his weight within six months. Spencer's growth in length and
head circumference is also within normal limits based on the above
information.
Regarding the caloric intake of exclusively breastfed babies,
Riordan and Auerbach write:
>> > Energy intakes of breastfed infants beyond the first month are well
>> > below the official Committee on Dietary Allowances (1980) and
>> > WHO/FAO (1980) recommendations.
>> >
>> > ...Stuff and Nichols (1989) found that energy intake of infants fed
>> > human milk was about 20% below recommended levels. Caloric content
>> > did not increase after solid food were added to the diet.
>> >
>> > Garza, Stuff, and Butte (1986) found that energy intakes of
>> > breastfed infants remained approximately 70 - 75 kcal/kg from the
>> > third month on. Energy requirements have been overestimated for
>> > breastfed infants because they have been based on volumes of formula
>> > required by artificially fed infants.
>> >
>> > The energy intakes of breastfed and formula-fed infants differ
>> > significantly. Total daily energy expenditure, minimal rates of
>> > energy expenditure, metabolic rates during sleep, rectal
>> > temperature, and heart rates are all found to be lower in breastfed
>> > infants. ... Another possibility is that the energy density of milk
>> > taken by a four month-old is higher on the average than that taken
>> > by the same baby three months earlier. The four-month-old baby's
>> > suckle is more active, leading to a higher fat intake with lower
>> > volumes needed -- i.e., breastmilk is more completely utilized with
>> > less wastage. (Pages 106-107)
>> >
>> > Fat content of milk is another variable to consider. The
>> > Breastfeeding Answer Book states:
>> >
>> > One study found that the fat content of milk varies among mothers
>> > and that babies whose mothers had lower-fat milk tended to nurse
>> > longer at feedings and take a greater percentage of the milk in the
>> > breast. Both groups of babies gained weight within the normal
>> > ranges... (Page 26)
>> >
>> > In Biocultural Perspectives, Michael Woolridge, studied the adaptive
>> > nature of the infant to self-regulate their intake of breastmilk. He
>> > found that baby-controlled feeding, or "demand" feeding pattern is
>> > best for the baby.
>> >
>> > He also found a variation in milk fat based on frequency of feeds.
>> >
>> > So ultimately, we must consider the factors that predict the mean
>> > feed milk fat concentration, as it is these that tell us whether
>> > milk quality is open to manipulation by changes in feeding practice.
>> >
>> > The factor that shows the highest association is the time elapsed
>> > since the previous feed and this shows an inverse relationship to
>> > mean feed fat concentration --the greater the interval the lower the
>> > average fat content. Thus, the more frequent the feeds, the higher
>> > the fat content. (Page 227)
>> >
>> > As I told you during our conversation and in our e-mail
>> > communication, Spencer as ready access to me 24 hours a day and I
>> > nurse him as often as he wants. Spencer trusts that I will nurse him
>> > when he wants, and I trust that he will take what he needs to sustain
>> > growth.
>> >
>> > I can ascertain that Spencer is receiving an adequate amount of milk
>> > by knowing that we have established a good latch and suck in the
>> > early days of his life, and he currently has good latch and swallows
>> > milk audibly. I also mentally note his daily output. Spencer has
>> > always had at least six wet diapers a day, and he has normal bowel
>> > movements (from once every other day up to two times a day.) When
>> > inquiring about a baby's breastfeeding, these are two very important
>> > issues. I always ask about latch and positioning, and wet and soiled
>> > diapers.
>> >
>> > It should be noted that Spencer rarely cries to be fed. His cries
>> > usually mean that he wants to be picked up, carried around, and
>> > played with.
>> >
>> > I do not feel that solids must be introduced by four or even six
>> > months. I wait until my baby seems ready. The cues I look for are
>> > the ability of the baby to sit up, and the ablity to pick up food and
>> > put it in his mouth (no tongue thrusting which will push food out of
>> > the mouth). Since solid foods will decrease the mother's milk supply
>> > during the first year of life, it is recommended that mother
>> > breastfeed the baby before offering solid foods. This will ensure
>> > that the baby is receiving the milk needed for growth. After the
>> > first year, it is appropriate to offer solid food first.
>> >
>> > The Breastfeeding Answer Book notes a study involving 141 mother-baby
>> > couples. The mothers exclusively breastfed their babies until sold
>> > foods were introduced at four months or later. Researchers noted
>> > that the energy value of the human milk the baby consumed when he was
>> > exclusively breastfeeding matched closely the combined energy value
>> > of human milk plus solid foods he took later. The researchers
>> > concluded that rather than increasing their intake of calories when
>> > solid foods were started, the babies balanced their mother's milk
>> > and solid food intake to maintain a stable intake of calories. The
>> > volume of the mother's milk dropped when solid foods were introduced
>> > (Cohen 1994). (Page 29)
>> >
>> > Unlike formula-fed babies, iron is efficiently absorbed by the
>> > breastfed baby, even into the second half of the first year of life.
>> > InBreastfeeding: Biocultural Perspectives, Patricia Stuart-Macadem
>> > states that:
>> >
>> > Infants absorb 50-70% of the iron in breast milk compared to 10% of
>> > the iron in cow's milk and 3-5% of the iron in iron-fortified
>> > proprietary formulas (Oski and Landaw, 1980). The introduction of
>> > supplemental foods in early infancy also has a detrimental effect on
>> > iron status because it impairs the bioavalibility of iron from human
>> > milk. Infants who are breastfed exclusively for periods of 6-9
>> > months maintain normal hemoglobin values and normal iron stores
>> > (Oski and Landaw, 1980). (Page 21)
>> >
>> > Riordan and Auerbach write:
>> > ...breastfed babies are rarely iron deficient. They maintain their
>> > iron status at the same level as formula-fed infants receiving iron
>> > supplements for up to nine months. (they site four studies)
>> > Breastfed infants are sustained by sufficient iron reserves laid
>> > down in utero, plus the high lactose and vitamin-C levels in human
>> > milk which facilitate absorption. (Page 115)
>> >
>> >
>> >
>> > The Breastfeeding Answer Book includes the following information on
>> > the issue of iron stores in breastfed babies:
>> >
>> > One study of breastfed babies who were not given iron supplements or
>> > iron-fortified cereals found that those who were exclusively
>> > breastfed for seven months or longer had significantly higher
>> > hemoglobin levels at one year than breastfed babies who received
>> > solid foods earlier than seven months (Pisacane 1995).
>> > (Breastfeeding Answer Book, page 144)
>> >
>> > Since I had a scheduled appointment at the pediatrician's office, I
>>> asked that they check Spencer's hemoglobin level. It is 13.0.
>>> Spencer is now seven months old, and still is exclusively
>>> breastfed. He takes no vitamin nor mineral supplements. It
>>> appears that he apparently does not need any iron
>>> supplementation.
>> >
>> > I'd like to note that babies should be breastfed beyond the first
>> > year of life. It is the norm in other cultures, and is the norm for
>> > our species. It is quite preferable to allow the child to initiate
>> > weaning from the breast. For more information on this, check out
>> > Katherine Dettwyler's chapters in Breastfeeding: Biocultural
>> > Perspectives and her web site at
>> > http://www.prairienet.org/laleche/dettwyler.html
>> >
>> > I hope this information helps you to better understand how
>> > breastfeeding a baby is quite different from formula-feeding a baby.
>> > Breastmilk is the healthiest food for baby and needs little
>> > supplementation until well into the second half of the first twelve
>> > months of life.
>> >
>> > Thanks again for sending me your analysis of Spencer's nutritional
>> > assessment. It certainly helps me understand why I need to continue
>> > our work of organizing our annual conference on breastfeeding and
>> > birth for area professionals. There is still so much work to be done
>> > to educate our society about the benefits of breastfeeding as well as
>> > identify the inaccuracies in the current literature and studies on
>> > the issue of infant nutrition and feeding.
>> >
>> > I hope to see you and your fellow students and professors at our
>> > conference in May of 1998. Of particular interest to Nutritionists
>> > would probably be Dr. Cheston Berlin's topic on the Value of
>> > Breastfeeding, which will include the adverse infant health outcomes
>> > when a baby receives commercial milk rather that breastmilk. He is
>> > our featured speaker on Thursday, May 7, and he will also address
>> > other topics as well during his presentation.
>> >
>> > Kathleen Auerbach is our featured speaker on Friday, May 8. She will
>> > speak on the Latest Research on breastfeeding, and address the
>> > necessity of follow-up for the postpartum mother. She will also
>> > speak on other topics during the day, and be available to answer
>> > questions from the audience.
>> >
>> > I'll send you a brochure in early winter. Scholarships will be
>> > available for the conference. I have learned so much from attending
>> > during these past three years. I hope you and your colleagues can
>> > attend.
>> >
>> > An additional on-line resource for breastfeeding information can be
>> > found on LactNet, a free e-mail usergroup. To join, send an internet
>> > e-mail to [log in to unmask] Leave the subject blank. In
>> > the body of the message, type: JOIN LACTNET Your first name and last
>> > name It is quite a lively discussion at times! I'm sure you'll learn
>> > lots!
Kathleen B. Bruce, BSN, IBCLC co-owner Lactnet,TLC, Indep. Consultant
http://together.net/~kbruce/kbbhome.html
LACTNET Archives http://library.ummed.edu/lsv/archives/lactnet.html
LACTNET WWW http://www.telcomplus.net/~kga/lactation.html
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