Dear Karleen, Pamela, Susan, and Alice,

Thank you very much for you input!

From all the responses I received I understood that we indeed do not have answers for the questions I posed in the original post. Karleen, I will contact Marko Kerac to see if he has seen anything. Susan, it has been very interesting to read about the history of direction changes in international organization policies. Pamela, you mentioned 600 ml in one of your very old LACTNET posts. It may be that that is about how much breastfed infant take in, anyway, but there will be no way to precisely measure it, so in clinical situations, breastfeeding would be hailed as imprecise and unreliable.

I would like to divert the discussion from "ORT works" to "what is the merit of ORT in breastfed children and which small subset of breastfed children indeed needs it as an addition to breastfeeding".

I would like to add some things to the discussion. 

1.	Exclusive breastfeeding during episodes of diarrhea or vomiting is not limited to infants under 6 months of age. I question current guidelines to offer additional fluids to children over 6 months. Most children as old as 3-4 years if they are breastfed (not token nursing, but unrestrictedly breastfed) refuse all food and drink during GI diseases in favor of the breast. They revert to newborn-like patterns of breastfeeding for the duration of the illness and longer to restore from the illness.
2.	Promotion of breastfeeding (a normal state) is essential, not because of Nestle, but because of historical and cultural context of
a)	devaluation of women’s ability to sustain life in the context of erroneous and prejudiced scientific ideas about women in 17-21th centuries; 
b)	promotion of technological solutions of non-existing problems (improvement of breastfeeding by regimenting it in the light of new technology and science, ideas about clocks and efficiency); 
c)	solutions of social ills by marriage of medical and business means (industrialization triggered separation of mothers and infants, migration of birth into hospitals, break-down of familial support – creation of formula, utilization of industrial dairy waste such as whey, skimmed milk); 
d)	solution of “savage world” issues by Western medicine (per Ivan Illich there is that Western medical solutions create more issues than solve, in this case mislabeled “protein gap” issue, kwashiorkor, a disease of premature weaning, that is subsequently starting in the 1950’s was “solved” by UNICEF among other “aid” agencies by dumping thousands (or millions?) of pounds of skimmed milk, read industrial waste, onto the third world countries to feed children to solve the protein gap issue; Nestle coincidentally intensified their promotion of formula during that time too).
3.	ORT was developed in the context of cholera epidemics claiming 20-30% of lives of those who came down with it. Not-coincidentally, IV therapies and oral therapies emerged right at the time when breastfeeding was waning because of the reasons mentioned above and in the context mentioned above. While it is considered an improvement on IV use, industrialized world does not use this therapy much and favors IVs (for a variety of reasons – time, financial reimbursement, system of beliefs in medicine of what is better, etc.). It was not developed with breastfed children in mind or in the context of a breastfeeding culture or breastfeeding-friendly medical culture.
4.	ORT has been promoted as wonderfully side-effect free, but it was also called “a sweet killer”. Much of ORT development was experimental. ORT not only restores fluid-electrolyte balance, it also causes diarrhea. New low-solute ORT was developed as a result of a report by one mother that her child, in fact, suffers more diarrhea after she gives the solution. During that same time formula became low solute. 
5.	Comparisons of adult ORT and non-breastfed child ORT and extrapolation of its merits in non-breastfed populations are not evidence of ORT benefit in breastfed children.
6.	By the time that ORS is needed, the infant or child or even adult is in danger of dying.  That person has already been infected with pathogens.  Hopefully they have started treatment for those pathogens.
Susan, infection by pathogens does not mean that a breastfed child is in danger of dying. Not all pathogens require treatment and not all pathogens respond to treatment. Breastmilk has antibodies for many gastroenteritis causing pathogens, which means, that breastfeeding becomes therapy during acute episode of GI illness.
Which breastfed infants are in danger of lethal dehydration? What are the screening means for this small subset within a breastfed population (rhetorical question)?
7.	Fasting guidelines during ORT, which includes suspension of breastfeeding, are alive and well within the medical field as a result of almost 100 year old prejudices that appeared at the time of breastfeeding decline and rise of formula.
8.	WHO and UNICEF started promotion of ORT in mid-1970’s during cholera outbreaks. Baby Killer appeared in mid-1970 and gave rise to Nestle Boycott. Breastfeeding promotion of breastfeeding by WHO did not start until early 1980’s. 
9.	Alice, you picked up on the issue that I am talking about. ALL promotional literature on diarrhea management and dehydration prevention is either mute on the subject of breastfeeding or has a feeling mention of breastfeeding. This includes educational literature for healthcare professionals. This means that the feeling, the perception of people who are exposed to this literature is that ORT is number 1 and breastfeeding is number 2, at best. Most of the time breastmilk is hurdled with carrot soup (1950’s empirical finding from Scandinavia), rice water or such. The incidence of breastfeeding mentioning is appallingly low. Breastfeeding is usually mentioned within the text or last, not first. This means that its importance is lost in the text by positioning it in such a way, that it is not obvious and clear how vitally important it is.
10.	Alice, again, you picked up on another issue - making solutions with water in conditions that have limited access to clean water to begin with. When I researched this issue I came upon staggering examples of the absence of logic – diarrhea happens during cholera outbreaks when there is limited supply of clean water, a great way to prevent dehydration in children is to make a solution with water, salt and sugar. No mention of breastfeeding.



Natalie Wilson
La Leche League of North Carolina

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