On 12/13/2014 10:34 AM, Maureen MINCHIN wrote:
> There's no basis for the 500mL; it's formula that should be no more than that by 12 months so that the child eats other food. I am seeing children drinking a litre, up to two, and not eating.

/*Besides the absurdity of measuring the breast milk the baby receives 
at the breast, we are also dealing with the basic math problem - meaning 
the problem with math itself. *//*
*//*Let's do simple calculations - 500 cc is 2-2.5 cups (or bottles) of 
fluids that is not too much actually. The average for a kid at this age 
would be about 750 cc. Again, everything will depend on the individual 
situation. Also, it will depend on what family would consider "fluid" 
and "drinking". Had families requesting interventions, multivitamins and 
medications increasing appetite for kids who would not eat anything 
during the day drinking only water. On further questioning (sometimes - 
further interrogations) it will turn out that the kid would EAT 2-3 
bottles (the same 500-750cc) of buttermilk with soft cheese and cereal 
per night (to say nothing about cookies and milk during the day).
Grrr... */

> As for iron fortification: if the child has a good supplementary diet the worry is likely to be that fortified cereals provide iron in excess, and that this negatively affects cognitive development increases oxidative risks which may include promoting cancer, and assists pathogens.

/*Iron supplementation of the exclusively breastfed baby is an issue in 
its own that should not be taken out of the context. While I do agree 
with Maureen's comments here, I have to admit that iron deficiency is 
real and it can hurt the kid as much (if not worse) as iron overload 
would. Especially if the most nutrition is still coming from the breast 
milk for this kid, I would definitely recommend supplementation of the 
mother. 10 mo old baby is exactly at the period of life when his iron 
reserves are on the low side and evaluation for possible anemia is 
recommended (at  least in United States such screening is mandated). I 
prefer to check both complete blood count and iron levels, as some times 
one can have "anemia" (read - low hemoglobin levels) with mild 
hereditary anemia traits, that are not always picked up on the neonatal 
screening at birth. Evaluating indexes and comparing that picture with 
several iron studies will give the better understanding of the situation 
and thus- prevent both under treating and overdosing this particular 
kid.  I did try to find any formal recommendation for anemia screening 
in Norway, only finding some articles of very small studies and that's it.

I also have to chime in on the premises of cereal as a first food and 
the baby food vs family foods in general. The concept of the baby foods 
comes from the idea that babies are not made to eat adult food and thus 
have to have something entirely different and special made for them. 
This concept works when parents have horrible diet either by adversity 
(extreme poverty) or by choice (poor eating habits). But provision of 
baby foods either by cooking separate meals or by using manufactured 
staff in boxes, cans and tubes can have a significant adverse effect on 
the family nutrition in general and on the kid's nutrition in 
particular. By relying on "special baby foods" and thus by not 
addressing infant nutrition as a part of the family nutrition from the 
very beginning of PREGNANCY we are losing the opportunity to provide 
family with nutritional skills that they will carry on through the 
pregnancy, lactation, and thereafter. The demand to cook separately for 
the child (like it is done in areas where I came) puts additional 
financial and organizational burden on the family and pushes parents to 
turn to the dark side of manufactured "baby foods".

Which brings us to the concept of cereals as a first food, which is a 
not good thing all together *//*/*high carbohydrate overload and its 
intrinsic sweetness*/. No matter what will be written on the box 
(including "organic", "whole grain", "gluten free". "iron fortified" and 
so on) processed food is a processed food is a processed food and we 
should be advocating against it as much as possible, at least to the 
reliable families that can and that are interested in proper nutrition 
for parents and kids. For families that consider re-fried beans from 
Taco Bell take out (equivalent of McDonald's) as a vegetable, definitely 
manufactured baby foods, including the cereals, will be a much better 
choice. But as I can assume, that was not a situation in Rachel's case. */

> Has the PHN been talking to a  formula rep and got the 500ml there, assumed breastmilk the same as formula?

/*Again, even formula reps would not give you the 500 cc volume, but 
keep in mind that most of the artificial milks manufacturers are also in 
the baby food and (no comment about it) in the toddler foods business too.*/

> Anyway, how is she to measure the 500ml when breastfeeding. DUH. Just offer three meals, 2 snacks as WHO suggests, and let baby decide what to eat. Good literature on complementary foods on WHO website and also First Steps Nutrition Trust in the UK.
*/
/**/Exactly. And using words "complimentary foods" or "family foods" is 
extremely important./**/
/**/Unfortunately many health care providers (physicians, nurses and 
educators) are still being taught in terms of "baby foods" as the only 
nutrition for infants and toddkers, "jars" as a measure of the volume 
and "stages" as a measure of the texture :(./**/
/**/
/**/For Rachel - I would treat this situation as a great educational 
opportunity both for the mother, for the PHN (was it a public health 
nurse?) and for the community in general./**/
/**/What about compiling the cookbook with the local family friendly 
recipes that would satisfy (with some minor alterations for texture and 
spiciness) the whole family - parents, older kids and babies? /**/
/**/Having pediatricians, dieticians, lactation consultants and PHNs on 
a selection committee would create such an avenue for open discussion 
and thus - an opportunity for a change./**/
/**/
/**/Alla /*

-- 
Alla Gordina, MD, IBCLC, FAAP
General Pediatrics
Breastfeeding Medicine
Adoption and Foster Care Medicine

Global Pediatrics and Family Medicine
NJ Breastfeeding Medicine Education Initiative
NJ Chapter Breastfeeding Co-Coordinator, American Academy of Pediatrics
Satellite Symposia Sub-Committee Chair, Academy of Breastfeeding Medicine


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