Dear all:

Since the causes of an infant undereating are so multifaceted in my area of the world, I 
had long ago stopped using the term insufficient milk production in talking to women.  
Nor do I use the terms failure to thrive or inadequate intake.  Usually, I mention that the 
baby is undereating and focus on finding a culturally appropriate solution that a woman is 
likely to be able to adopt and follow based on in-depth discussion with her.  This varies 
highly since Manhattan does have a huge variation in cultural backgrounds.  At any one 
time in my clinic, I often will have both a slow gaining baby that is thriving but petite, as 
well as another baby who is gaining at exactly the same rate that is NOT thriving.  
Exploration of factors beyond just the weight are crucial.  The differences are in the 
baby's behavior and development.  A mere dismisal of the possibility that some babies 
may not be eating enough to meet their needs is not sufficient.

On the topic of environmental problems such as those proposed by Lisa Marasco, I have 
to agree that we will continue to see this more and more.  Furthermore, I know that this 
is even MORE of a problem in developing countries where pollutants, particularly those 
used in agriculture are dumped because standards have not yet been established to 
protect the public from their effects.  Erosion has also caused an increase in the depletion 
of iodine in the soil and increases in iodine deficiency in many areas of the world.  Iodine 
deficiency leads to hypothyroidism --- which can throw off milk production.  

No one has mentioned the most challenging problem that we face in most of the world -- 
which is morbid obesity. While the rise in morbid obesity is astronomical here in the 
United States it is also on the rise even in developing areas of the world and it has clear 
implications in insulin reglation and thyroid function.  Those large breasts that are large 
because they are packed with milk producing cells are one thing.  Those large breasts 
that are merely full of fatty tissue and may not have developed sufficient milk producing 
cells during an adolescence of overeating inexpensive meats from corn-fed overstuffed, 
growth hormone infused livestock and a wealth of readily available and inexpensive corn-
syrup infused snacks with inadequate opportunity for healthy excercise --- are an entirely 
different matter. 

Even without considering any medical interventions, the number of interruptions a mother 
and infant have during a hospital stay is enough to throw many mothers and babies out of 
sync.  Quite frankly, I rarely see a mother whose baby has not been fed formula in the 
hospital, most frequently without her permission.  Then there is the plethora of lies 
perpetuated in this culture about how you really can have the same life you had before 
you had the child just by setting appropraite limits with those manipulating little creatures 
who are born to make your life a misery if you let them.  

I have to say that I do see at least 1-3 "marasmic" babies a year from a variety of 
different causes.  This is a clinical term that has been widely used in developing 
countries.  These are the babies that are avid and alert, won't complain if they don't get 
enough, cheeks and thighs are gaunt.  If you put a photo of these babies side by side with 
a "starving third world baby" photo used by aid organizations to gain sympathetic 
donations you would not be able to tell the difference except perhaps by the quality of the 
clothing.  Some of these babies were deemed "healthy" by health care practitioners 
because, by the scale, they were within normal limits of 1/2 ounce per day or because 
someone told them "there is no such thing as insufficient milk".  Usually mom's own 
observations of the baby's behavior and development were dismissed.  While the path to 
marasmus may differ in developing areas and here, I see no difference between the 
babies I have seen with this condition once they end up in that state.  These babies gain 
weight and feed more vigorously from their mothers once they are "supplemented" as 
warrented by the specific circumstances with either more frequent feeding at the breast, 
or from a substitute device with mom's own milk or when necessary from someone else's 
milk or an artificial substitute.  Just because some populations may live in a so-called 
developed area of the world, have a high income, or have light skin dosn't mean that 
marasmus doesn't occur in those populations.  

So, even though I would love to return to some magical time when, or natural place 
where, all mothers and babies were in sync and milk always flowed, I must contend with 
the present reality in my location that mothers and babies need empathetic listening to 
help devise plans for them to regain synchrony with each other in their feeding 
relationship.  And I will use whatever tool works best for that particular circumstance.

Best, Susan

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