Dear Susan,

Thank you for sharing your real life observations in developing countries! I find that what we see ourselves is often more telling than what we learn from lectures and books.

I would like to keep our discussion on track of differentiation of different groups of children and different recommendations for breastfed children vs. otherwise fed children.

1.	I mention the context of culture and history as significant because medical and WHO, UNICEF policies are developed in Western context, not the context of developing countries. It is Western ideas about women, breastfeeding, and breastmilk that influence what language and what order of interventions or solutions for diarrhea are developed. We use this literature all over the world.
2.	Nutritional programs and pamphlets are not diarrhea management literature. I specifically pointed out that there is a discrepancy between different programs. Breastfeeding is not prominent in literature on diarrhea management.
3.	Discussion of death leads us away from looking for evidence on use of ORS in breastfed children and comparisons of breastfeeding and breastfeeding with ORS. I am looking for research that will clearly delineate breastfeeding groups which may benefit from this therapy. Currently there are recommendations to start ORS immediately in ALL children, whether breastfed or not. A tiny portion of materials (you have to look HARD to find those) may exclude breastfed children with no signs of dehydration.
4.	Dehydration signs and symptoms within diarrhea literature are very inconsistent. There is no distinction between dehydration as a process of losing water and electrolytes and dehydration as a state when treatment is required. 

As of today, the question stands on research that will specifically look at groups of breastfed children who do not need therapy and those who may benefit from it. 

Natalie Wilson
La Leche League of North Carolina

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