feeding failure, severe
cases
percents of
not
only
in the three
noted, but in large
noted in the survey that I conducted in 1974, the physician played a very minimal role in a woman's decision to start breast-feed¬ ing. The physician's role should be to support the woman's decision whenev¬ er medically possible. As far as can be ascertained from this article, no attempt was made to reinitiate sup¬ plemented breast-feeding in any case. The mother has been labeled a failure by her physician. These are aspects that training programs rarely cover comment.
women as
According
to
MIRIAM LABBOK, MD, MPH 2022 N 21st St Arlington, VA 22201
1. Benson R: Obstetrics and Gynecology. Medical Publications, 1977, p 117.
Lange
and Malnutrition
Sir.\p=m-\Gilmoreand Rowland (Journal 132:885-887,1978) report three cases of critical malnutrition in breast-fed infants. In my office (albeit in slightly milder form), this has been termed the
"Buchenwald-baby
syndrome,"
a
breast-feeding, having
an-
that I would now like to suggest to others. These babies can be identified by our aide who notices that when the marasmic-appearing infant is weighed at the time of the first monthly visit, there is little comment by the mother although the infant weighs about the same as at birth. All of the mothers have a strong commitname
ment to
practice.
a
sufficiently.
Breast-feeding
in our hospital clinic, with some varia¬ tions from the pattern seen in private
nounced these plans during or prior to pregnancy. As noted by Gilmore and Rowland, the mothers did not seem worried, and we have noticed that they do not call us for advice during the first month of life as other primipara usually do. Although the appearance of the infants is alarming to us, the mothers are not only not alarmed, but hasten to report that the infants are satisfied and do not cry, and express bewilderment at the idea that the babies might be malnourished. Suggestions that breast-feeding be discontinued are resisted, but our practice is to insist that the baby be wholly bottle-fed for one week and brought back to the office for another examination; at that time the infants have generally gained half a kilogram, which reassures us that there is noth¬ ing else to account for the malnutri¬ tion. I have seen one other severe case
Report of a Case.-This infant was the seventh born to a 37-year-old mother, who brought in the baby at age 7 weeks because he was "too thin." Birth weight had been 3,240 g and weight now was 2,480 g. The mother said the infant behaved normally, sucking well, smiling, and having a bowel movement every second day. Results of physical examination were normal, except for the lack of any subcutaneous tissue and a body temperature of 34.8 °C. The periph¬ eral blood count results showed a hemoglo¬ bin level of 17 g/dL, a hematocrit level of 51%, a WBC count of 2,000/cu mm with 26% polymorphonuclear leukocytes, and a plate¬ let count of 30,000/cu mm. The results of a bone-marrow examination were unremark¬ able and the only other abnormality in the results of the routine laboratory studies was hypoproteinemia, with albumin level of 2.5 g and total protein level of 4.5 g/dL. With hospital formula feeds, the leukopenia and thrombocytopenia improved daily and were no longer apparent after five days. The patient was discharged on formula feeds and did well subsequently. Comment— As indicated by Gilmore and Rowland, unrecognized breast¬ feeding malnutrition (what we term the "Buchenwald-baby syndrome") may lead to life-threatening conse¬ quences. It is difficult to understand why an intelligent mother would not respond appropriately to the visual stimulus of her marasmic baby. The answer may lie in the La Leche League literature, where, in the chap¬ ter entitled "Best for Baby-Best for You," it states: "Breast-feeding is an integral part of good mothering."1 It may be necessary to reassure some mothers that breast-feeding is not an essential part of being a good mothJERRY C. JACOBS, MD Department of Pediatrics Section of Rheumatology College of Physicians & Surgeons of Columbia University New York, NY 10032 1. The Womanly Art of Breast Feeding. Franklin Park, Ill, La Leche League Internation-
al, 1963,
p 10.
Breast-feeding
and Malnutrition
Sir.\p=m-\Therecent report "Critical Malnutrition in Breast-fed Infants"
(Journal 132:885-887,1978) presented
three cases of severe malnutrition in breast-fed infants. The authors im-
plied that these cases represent primary inadequacy of lactation, while they have understated the more likely causes. In case 1, the probable factor responsible for undernutrition was the initial four-hour feeding interval.
Breast milk has a finer curd than formula and is absorbed faster, indicating that breast-fed babies should nurse at least every three hours for proper nutrition.1.2 In case 2, insufficient nutrition was probably due to the accumulative effects of the combination of oxycodone, aspirin, phenacetin, and caffeine (Percodan) in the breast milk, which caused sleepiness, lack of crying, and decreased vigor of nursing. A review of drugs in breast milk by one of us (L.W.) showed that there is no information on this drug in breast milk.3 However, this case would make us hesitate to prescribe this drug for breast-feeding mothers in the future because an infant lacking the enzymes to metabolize the drug might experi¬ ence an accumulative drug effect. Diazepam (Valium) can produce leth¬ argy and weight loss in an infant.4 In case 3, the most likely cause of the infant's malnutrition was giving 60 to 90 mL of water between feed¬ ings. It is well established that water or formula supplements given before lactation may cause the baby to reject the breast, either because the stomach is already partially filled or because the easier-flowing bottle nipple trains the infant to nurse less vigorously.2 We disagree with the authors' man¬ agement of the insufficient lactation. If these women wanted to continue breast-feeding, they should have been helped to relactate.7" Instead, the breast-feeding was discontinued and the infants were placed entirely on a regimen of formula. In the very rare case in which the milk supply does not increase sufficiently during relacta¬ tion (as in the case of women with inadequate prenatal development of lobuloalveolar tissue, as evidenced by only slight increase in breast size
during pregnancy," breast-feeding
still be continued for some nutri¬ tion and for sucking and emotional needs while formula fills most of the nutritional needs. An advantage to this mixed feeding is that it avoids burdening the mother with the guilt of failure in nursing. In conclusion, this report serves to alert physicians to the critical dangers can
posed by not giving detailed, accurate
Downloaded From: http://archpedi.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/24/2015
instructions about breast-feeding, in¬ cluding that the baby should have at
eight to ten wet diapers per day sign of adequate hydration. Secondly, the report makes clear the need for early follow-up of high-risk breast-feeding couples. High-risk in¬ fants include those with low Apgar scores (case 3), with low birth weight, or with other neonatal problems like hyperbilirubinemia (cases 1 and 2). High-risk mothers include those who have been physically ill (case 3) and/or those who require medication (case 2), those who have been emotionally ill during the postpartum period, or least as
a
those with inverted nipples or other breast problems. It is vital that physi¬ cians identify the at-risk population early and respond to their special needs with instruction and support. LUCY R. WALETZKY, MD Department of Psychiatry
Georgetown University Hospital ELINOR BOND MARTIN
Georgetown University School
of Medicine 3800 Reservoir Rd, NW Washington, DC 20007
1. Egli GE: The influence of the number of breast-feedings on milk production. Pediatrics 27:314, 1961. 2. Appelbaum RM: The modern management of successful breast-feeding. Pediatr Clin North Am 17:203-225, 1970. 3. Yaffee S, Waletzky L: Drugs and pollutants in human milk, in Waletzky, L (ed): Human Lactation Symposium. Washington, DC, Office of Maternal and Child Health, Department of Health, Education and Welfare, in press. 4. Patrick MJ, Tilstone WJ, Reavey P: Diazepam and breast-feeding. Lancet 1:542-543, 1972. 5. Waletzky L, Herman E: Relactation. Am Fam Physician 14:69-74, 1976. 6. Hytten FE: The physiology of lactation. J Hum Nutr 30:225-232, 1976.
Reply.\p=m-\Thediversity of verbal and written responses (and abuse) we have received concerning our case reports of critically malnourished breast-fed babies (Am J Dis Child 132:885-887, 1978) is well illustrated by the letters from Jacobs, Waletzky and Martin, Kutnik, and Labbock. The comments of many pediatricians appear to support the contention that inadequate weight gain by breast-feeding babies is more common than is generally recognized. At the same time\p=m-\andthis we also wished to emphasize\p=m-\successful breast-feeding requires careful instruction and support by medical and paramedical personnel, and early follow-up for primiparous mothers is particularly important. The point of our article was that parents, nurses,
and into
physicians should not be lulled assuming that simply because a baby is breast-feeding, he or she is receiving sufficient nourishment. We are not sure why the babies reported in our series failed to receive enough breast milk. We doubt that the small amounts of
a
combination of
oxycodone, aspirin, phenacetin, and caffein (Percodan), a semisynthetic narcotic analgesic, was responsible in case 2. Opiate medications occur in only small quantities in breast milk1;
adverse effects have been observed in babies breast-feeding from moth¬ ers on methadone maintenance, and maternal ingestion of drugs such as no
meperidine hydrochloride, morphine, and propoxyphene hydrochloride are
not believed to
represent a risk
to the
nursing infant.2
We find ourselves concerned, how¬ regarding the suggestion in two letters that breast-feeding should have been resumed after the nearcatastrophic illnesses of these babies. The emotional reactions of the moth¬ ers to nursing failure that led to the near-death of their infants was expectedly severe. To attempt reesta¬ blishment of breast-feeding, we be¬ lieved, would be contrary to the emotional needs of the mother and of the baby, as well as posing undefined medical risks to the infant. Assuring the parents (and physicians) that adequate nourishment could be rap¬ idly reinstituted by bottle-feeding clearly outweighed the nutritional advantages of breast-feeding in these ever,
cases.
THOMAS W. ROWLAND, MD HERBERT E. GILMORE, MD 759 Chestnut St Springfield, MA 01107
In
1.
Drugs in
16:25, 1974.
breast milk. Med Lett
Drugs
Ther
2. Wing JP: Human versus cow's milk in infant nutrition and health: Update 1977. Curr Prob Pediatr 8:27, 1977.
Acute
Suppurative Thyroiditis
Sir.\p=m-\Abeet al raised the number of to my knowledge of recurrent suppurative thyroiditis reported in the literature from two to four (Am
cases
acute
J Dis Child 132:990-991, 1978). A fifth case has occurred, which was particularly refractory to management both by antibiotics and by simple drainage. Report of a Case.\p=m-\A1-year-old girl was noted to have acute onset of a swelling in the thyroid area, with thickening, tender-
overlying skin. A "bone-hard" mass was palpated, which felt like "two walnuts connected in the center." The swelling was preceded by an upper respiratory infection with profuse nasal discharge of one week's duration that was treated symptomatically. The patient's temperature was 39.0 \s=deg\Cand her WBC count was 19,000/cu mm. Results of all thyroid studies, including those of antibodies, were normal, and a thyroid scan showed very little trapping of isotope in the gland. She was treated with cephalexin and the swollen mass gradually subsided to the size of a peanut. Nine days later, the swelling reappeared acutely, accompanied by fever and redness, and tenderness of the overlying skin. She was given cefazolin intravenously for 24 hours, followed by incision and drainage of 6 mL of pus, cultures of which grew ahemolytic streptococcus and Klebsiella pneumoniae, sensitive to cephalexin. She was discharged home four days later on a regimen of cephalexin and five months later the wound appeared to be completely healed, with no residual swelling. Two months later, fever and cervical swelling reappeared. After treatment with nafcillin sodium and gentamicin sulfate for four days, the abscess was drained and ness, and redness of the
packed
open. and Klebsiella
a-Hemolytic streptococcus organisms again grew from
cultures. Over the next month, the wound grad¬ ually closed, but swelling and spontaneous drainage continued to occur almost weekly. Therefore, eight months after her initial
presentation, she underwent surgical ex¬ ploration of her neck. The draining sinus tract was found to communicate with
a
cavity that extended both anteriorly and posteriorly as well as cephalad to both lobes of the thyroid gland, but not into the gland itself. The lining of the cavity was excised and the deep cephalad tract was excised, along with the midportion of the hyoid bone. The wound was allowed to heal by secondary intention. The tissue removed was identified histologically as granulation tissue that contained a few thyroid folli¬ cles. No epithelium could be identified. Seven months after this major procedure was performed, the child was well healed, with
no
evidence of
recurrence.
Comment—The resistance of this infection to medical and surgical management seems to have been due to a thyroglossal duct remnant that was contiguous to the thyroid gland. ANTHONY
SHAW, MD
University
of
Center
Virginia
Medical
Charlottesville, VA 22908 Name and Trademark of Drug
Nonproprietary Gentamicin
Downloaded From: http://archpedi.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/24/2015
sulfate-Garamí/ciíi.
cases
percents of
not
only
in the three
noted, but in large
noted in the survey that I conducted in 1974, the physician played a very minimal role in a woman's decision to start breast-feed¬ ing. The physician's role should be to support the woman's decision whenev¬ er medically possible. As far as can be ascertained from this article, no attempt was made to reinitiate sup¬ plemented breast-feeding in any case. The mother has been labeled a failure by her physician. These are aspects that training programs rarely cover comment.
women as
According
to
MIRIAM LABBOK, MD, MPH 2022 N 21st St Arlington, VA 22201
1. Benson R: Obstetrics and Gynecology. Medical Publications, 1977, p 117.
Lange
and Malnutrition
Sir.\p=m-\Gilmoreand Rowland (Journal 132:885-887,1978) report three cases of critical malnutrition in breast-fed infants. In my office (albeit in slightly milder form), this has been termed the
"Buchenwald-baby
syndrome,"
a
breast-feeding, having
an-
that I would now like to suggest to others. These babies can be identified by our aide who notices that when the marasmic-appearing infant is weighed at the time of the first monthly visit, there is little comment by the mother although the infant weighs about the same as at birth. All of the mothers have a strong commitname
ment to
practice.
a
sufficiently.
Breast-feeding
in our hospital clinic, with some varia¬ tions from the pattern seen in private
nounced these plans during or prior to pregnancy. As noted by Gilmore and Rowland, the mothers did not seem worried, and we have noticed that they do not call us for advice during the first month of life as other primipara usually do. Although the appearance of the infants is alarming to us, the mothers are not only not alarmed, but hasten to report that the infants are satisfied and do not cry, and express bewilderment at the idea that the babies might be malnourished. Suggestions that breast-feeding be discontinued are resisted, but our practice is to insist that the baby be wholly bottle-fed for one week and brought back to the office for another examination; at that time the infants have generally gained half a kilogram, which reassures us that there is noth¬ ing else to account for the malnutri¬ tion. I have seen one other severe case
Report of a Case.-This infant was the seventh born to a 37-year-old mother, who brought in the baby at age 7 weeks because he was "too thin." Birth weight had been 3,240 g and weight now was 2,480 g. The mother said the infant behaved normally, sucking well, smiling, and having a bowel movement every second day. Results of physical examination were normal, except for the lack of any subcutaneous tissue and a body temperature of 34.8 °C. The periph¬ eral blood count results showed a hemoglo¬ bin level of 17 g/dL, a hematocrit level of 51%, a WBC count of 2,000/cu mm with 26% polymorphonuclear leukocytes, and a plate¬ let count of 30,000/cu mm. The results of a bone-marrow examination were unremark¬ able and the only other abnormality in the results of the routine laboratory studies was hypoproteinemia, with albumin level of 2.5 g and total protein level of 4.5 g/dL. With hospital formula feeds, the leukopenia and thrombocytopenia improved daily and were no longer apparent after five days. The patient was discharged on formula feeds and did well subsequently. Comment— As indicated by Gilmore and Rowland, unrecognized breast¬ feeding malnutrition (what we term the "Buchenwald-baby syndrome") may lead to life-threatening conse¬ quences. It is difficult to understand why an intelligent mother would not respond appropriately to the visual stimulus of her marasmic baby. The answer may lie in the La Leche League literature, where, in the chap¬ ter entitled "Best for Baby-Best for You," it states: "Breast-feeding is an integral part of good mothering."1 It may be necessary to reassure some mothers that breast-feeding is not an essential part of being a good mothJERRY C. JACOBS, MD Department of Pediatrics Section of Rheumatology College of Physicians & Surgeons of Columbia University New York, NY 10032 1. The Womanly Art of Breast Feeding. Franklin Park, Ill, La Leche League Internation-
al, 1963,
p 10.
Breast-feeding
and Malnutrition
Sir.\p=m-\Therecent report "Critical Malnutrition in Breast-fed Infants"
(Journal 132:885-887,1978) presented
three cases of severe malnutrition in breast-fed infants. The authors im-
plied that these cases represent primary inadequacy of lactation, while they have understated the more likely causes. In case 1, the probable factor responsible for undernutrition was the initial four-hour feeding interval.
Breast milk has a finer curd than formula and is absorbed faster, indicating that breast-fed babies should nurse at least every three hours for proper nutrition.1.2 In case 2, insufficient nutrition was probably due to the accumulative effects of the combination of oxycodone, aspirin, phenacetin, and caffeine (Percodan) in the breast milk, which caused sleepiness, lack of crying, and decreased vigor of nursing. A review of drugs in breast milk by one of us (L.W.) showed that there is no information on this drug in breast milk.3 However, this case would make us hesitate to prescribe this drug for breast-feeding mothers in the future because an infant lacking the enzymes to metabolize the drug might experi¬ ence an accumulative drug effect. Diazepam (Valium) can produce leth¬ argy and weight loss in an infant.4 In case 3, the most likely cause of the infant's malnutrition was giving 60 to 90 mL of water between feed¬ ings. It is well established that water or formula supplements given before lactation may cause the baby to reject the breast, either because the stomach is already partially filled or because the easier-flowing bottle nipple trains the infant to nurse less vigorously.2 We disagree with the authors' man¬ agement of the insufficient lactation. If these women wanted to continue breast-feeding, they should have been helped to relactate.7" Instead, the breast-feeding was discontinued and the infants were placed entirely on a regimen of formula. In the very rare case in which the milk supply does not increase sufficiently during relacta¬ tion (as in the case of women with inadequate prenatal development of lobuloalveolar tissue, as evidenced by only slight increase in breast size
during pregnancy," breast-feeding
still be continued for some nutri¬ tion and for sucking and emotional needs while formula fills most of the nutritional needs. An advantage to this mixed feeding is that it avoids burdening the mother with the guilt of failure in nursing. In conclusion, this report serves to alert physicians to the critical dangers can
posed by not giving detailed, accurate
Downloaded From: http://archpedi.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/24/2015
instructions about breast-feeding, in¬ cluding that the baby should have at
eight to ten wet diapers per day sign of adequate hydration. Secondly, the report makes clear the need for early follow-up of high-risk breast-feeding couples. High-risk in¬ fants include those with low Apgar scores (case 3), with low birth weight, or with other neonatal problems like hyperbilirubinemia (cases 1 and 2). High-risk mothers include those who have been physically ill (case 3) and/or those who require medication (case 2), those who have been emotionally ill during the postpartum period, or least as
a
those with inverted nipples or other breast problems. It is vital that physi¬ cians identify the at-risk population early and respond to their special needs with instruction and support. LUCY R. WALETZKY, MD Department of Psychiatry
Georgetown University Hospital ELINOR BOND MARTIN
Georgetown University School
of Medicine 3800 Reservoir Rd, NW Washington, DC 20007
1. Egli GE: The influence of the number of breast-feedings on milk production. Pediatrics 27:314, 1961. 2. Appelbaum RM: The modern management of successful breast-feeding. Pediatr Clin North Am 17:203-225, 1970. 3. Yaffee S, Waletzky L: Drugs and pollutants in human milk, in Waletzky, L (ed): Human Lactation Symposium. Washington, DC, Office of Maternal and Child Health, Department of Health, Education and Welfare, in press. 4. Patrick MJ, Tilstone WJ, Reavey P: Diazepam and breast-feeding. Lancet 1:542-543, 1972. 5. Waletzky L, Herman E: Relactation. Am Fam Physician 14:69-74, 1976. 6. Hytten FE: The physiology of lactation. J Hum Nutr 30:225-232, 1976.
Reply.\p=m-\Thediversity of verbal and written responses (and abuse) we have received concerning our case reports of critically malnourished breast-fed babies (Am J Dis Child 132:885-887, 1978) is well illustrated by the letters from Jacobs, Waletzky and Martin, Kutnik, and Labbock. The comments of many pediatricians appear to support the contention that inadequate weight gain by breast-feeding babies is more common than is generally recognized. At the same time\p=m-\andthis we also wished to emphasize\p=m-\successful breast-feeding requires careful instruction and support by medical and paramedical personnel, and early follow-up for primiparous mothers is particularly important. The point of our article was that parents, nurses,
and into
physicians should not be lulled assuming that simply because a baby is breast-feeding, he or she is receiving sufficient nourishment. We are not sure why the babies reported in our series failed to receive enough breast milk. We doubt that the small amounts of
a
combination of
oxycodone, aspirin, phenacetin, and caffein (Percodan), a semisynthetic narcotic analgesic, was responsible in case 2. Opiate medications occur in only small quantities in breast milk1;
adverse effects have been observed in babies breast-feeding from moth¬ ers on methadone maintenance, and maternal ingestion of drugs such as no
meperidine hydrochloride, morphine, and propoxyphene hydrochloride are
not believed to
represent a risk
to the
nursing infant.2
We find ourselves concerned, how¬ regarding the suggestion in two letters that breast-feeding should have been resumed after the nearcatastrophic illnesses of these babies. The emotional reactions of the moth¬ ers to nursing failure that led to the near-death of their infants was expectedly severe. To attempt reesta¬ blishment of breast-feeding, we be¬ lieved, would be contrary to the emotional needs of the mother and of the baby, as well as posing undefined medical risks to the infant. Assuring the parents (and physicians) that adequate nourishment could be rap¬ idly reinstituted by bottle-feeding clearly outweighed the nutritional advantages of breast-feeding in these ever,
cases.
THOMAS W. ROWLAND, MD HERBERT E. GILMORE, MD 759 Chestnut St Springfield, MA 01107
In
1.
Drugs in
16:25, 1974.
breast milk. Med Lett
Drugs
Ther
2. Wing JP: Human versus cow's milk in infant nutrition and health: Update 1977. Curr Prob Pediatr 8:27, 1977.
Acute
Suppurative Thyroiditis
Sir.\p=m-\Abeet al raised the number of to my knowledge of recurrent suppurative thyroiditis reported in the literature from two to four (Am
cases
acute
J Dis Child 132:990-991, 1978). A fifth case has occurred, which was particularly refractory to management both by antibiotics and by simple drainage. Report of a Case.\p=m-\A1-year-old girl was noted to have acute onset of a swelling in the thyroid area, with thickening, tender-
overlying skin. A "bone-hard" mass was palpated, which felt like "two walnuts connected in the center." The swelling was preceded by an upper respiratory infection with profuse nasal discharge of one week's duration that was treated symptomatically. The patient's temperature was 39.0 \s=deg\Cand her WBC count was 19,000/cu mm. Results of all thyroid studies, including those of antibodies, were normal, and a thyroid scan showed very little trapping of isotope in the gland. She was treated with cephalexin and the swollen mass gradually subsided to the size of a peanut. Nine days later, the swelling reappeared acutely, accompanied by fever and redness, and tenderness of the overlying skin. She was given cefazolin intravenously for 24 hours, followed by incision and drainage of 6 mL of pus, cultures of which grew ahemolytic streptococcus and Klebsiella pneumoniae, sensitive to cephalexin. She was discharged home four days later on a regimen of cephalexin and five months later the wound appeared to be completely healed, with no residual swelling. Two months later, fever and cervical swelling reappeared. After treatment with nafcillin sodium and gentamicin sulfate for four days, the abscess was drained and ness, and redness of the
packed
open. and Klebsiella
a-Hemolytic streptococcus organisms again grew from
cultures. Over the next month, the wound grad¬ ually closed, but swelling and spontaneous drainage continued to occur almost weekly. Therefore, eight months after her initial
presentation, she underwent surgical ex¬ ploration of her neck. The draining sinus tract was found to communicate with
a
cavity that extended both anteriorly and posteriorly as well as cephalad to both lobes of the thyroid gland, but not into the gland itself. The lining of the cavity was excised and the deep cephalad tract was excised, along with the midportion of the hyoid bone. The wound was allowed to heal by secondary intention. The tissue removed was identified histologically as granulation tissue that contained a few thyroid folli¬ cles. No epithelium could be identified. Seven months after this major procedure was performed, the child was well healed, with
no
evidence of
recurrence.
Comment—The resistance of this infection to medical and surgical management seems to have been due to a thyroglossal duct remnant that was contiguous to the thyroid gland. ANTHONY
SHAW, MD
University
of
Center
Virginia
Medical
Charlottesville, VA 22908 Name and Trademark of Drug
Nonproprietary Gentamicin
Downloaded From: http://archpedi.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/24/2015
sulfate-Garamí/ciíi.
